If you've been shopping for new coverage lately, you may have noticed that a lot of insurance policies have very low limits for prosthetic coverage. On top of that, it's pretty common that your copay goes up as the cost—and function—of the component increases. Insurance companies often want you and your medical team to compromise, i.e., opt for a less costly component that they're willing to pay for. So how do you get the most functional prosthetic devices without having to pay more out of pocket?
Sometimes your physician or prosthetist will also be your advocate. A doctor's letter and progress notes may convince the insurance company to pay for a more expensive component, or that the chosen hardware is the best suited to your medical needs.
But while your prosthetist will fight for you, you're the one paying the premium. Once you know which features are absolutely necessary and will benefit you the most overall, use these strategies to contain the cost of your prosthesis without having to compromise function, quality, or comfort.
Skip the Preparatory Prosthesis
Traditionally, the first prosthetic device you wear is temporary. You wear a preparatory prosthesis while your residual limb matures and changes shape following amputation surgery. After several months this temporary prosthesis inevitably becomes ill-fitting, at which point you'll be fitted with what's called a definitive prosthesis. Insurance companies only allow basic components for a preparatory prosthesis and they're more likely to cover higher end components at an earlier stage when receiving a definitive prosthesis and skipping the preparatory prosthetic phase.
Many prosthetists may argue that the benefits of going straight to a definitive prosthesis are two-fold when you're a new amputee. Not only are you exposed to more advanced components through a definitive prosthesis, but you may also avoid poor walking habits from using less sophisticated components early on. You'll also have the option for a foam cover, a component that wouldn't be covered with a preparatory prosthesis.
Note: One disadvantage if you're fitted for the definitive prosthesis right away, without a preparatory trial, your prosthetist will have to make an educated guess about which components you'll benefit from most. Without any historical use information, the potential for over or under providing exists, because it can be difficult for prosthetists to predict the future version of you. With that being said, if you have a share of the cost, doing it this way can save you money of the total cost of prosthetic care—one temporary and one definitive—versus a definitive and one simple socket change.
Select the Best Prosthetic Knee
In terms of cost of knees, there are 3 categories: friction-controlled, which is ideal for one-speed walkers and is available at the lower end of the price range; fluid-controlled, which is perfect for fast walkers and those that frequently vary their speed; and microprocessor, which is ideal for people with diverse functional abilities and is also the most expensive.
It's been found that certain popular knee features, like a manual knee lock, will add to your bill. It's important to understand what each feature does and whether you'll receive any benefit. When picking features for your prosthetic knee, ask your prosthetist which prosthetic knee will suit your needs today as well as into your future, preferably around 3-5 years down the road.
For more expensive components, trial periods offered by manufacturers can serve as additional evidence whether this is the right component for you, information that may influence your insurance company. Some manufacturers offer prosthetic feet and knee units that have a 30-day return window, for example. And if you do, you and your prosthetist will be more informed about the device's potential benefit, and better equipped to lobby the insurance company on your behalf.
Make A Strong Case
If your insurance company refuses to cover or authorize what your prosthetist is requesting, he or she will help you navigate the world of health insurance, which may or may not involve using different components.
To prepare the most convincing insurance claim possible keep a medical journal. Document any abrasions, blisters, or ongoing discomfort. If your gait or sense of balance have been negatively affected, you've fallen, or your mobility has been limited in some way by the prosthesis be sure to include those details in your claim or prosthetist's "letter of medical necessity." Record the dates of any doctor visits related to your issues. If your claim is initially rejected use the appeals process to fight.
Be Your Best Advocate
Remember that you're the patient and you have a voice and rights. If your health insurance company isn't supporting your needs and paying for the appropriate prosthetic care, it's critical that you appeal their decision and go through their appeals process. In extreme cases, sometimes the option to change health insurers exist, and it's something to consider.
Before you commit to a new health insurer, make sure you understand your health benefits and coverage when it comes to what the company will or won't cover, like medical equipment or what they consider as being "experimental." Figure out the co-pays and your future out of pocket costs. Understand how to file an appeal. If you're covered through your employer's insurance, check with your employer to see whether other health insurer options are available.