The AP's data analysis showed a nearly threefold increase in Medicare coverage for one model of foot prosthesis that features a shock absorber and costs about $6,500.
That seemed puzzling to Gilmer. His clinic had recently fitted a patient with that same kind of foot. But the patient is in his 20s and rides ATVs, plays basketball and works on cars.
"Most of our Medicare patients are not going out playing hoops every day," said Gilmer. Fitting a patient is an individualized process that takes into account many factors, not only physical activity.
Avalere senior vice president Nora Hoban said the data raise questions that need to be answered by further research.
Medicare spokesman Cook said the government is cracking down on fraud involving artificial limbs, saving taxpayers $867,000 in the past year.
But Medicare was unable to provide the AP the ages of beneficiaries who received the different types of artificial feet or the states where they live. Those two pieces of information could help start to find answers to the puzzle.
Officials acknowledge widespread deficiencies in documentation of medical necessity for all kinds of equipment, but they are concerned that tightening requirements could restrict access for seniors.
"We are committed to reducing improper payments and fraud, while ensuring that Medicare beneficiaries have access to the care and services that they need," said Cook.
The inspector general's report recommended that Medicare revise a scale of functional activity levels that clinicians use to help determine what kind of artificial limb is appropriate for a particular patient, based on that individual's lifestyle. It said definitions of the patient's potential for rehabilitation should be clarified.
"These changes would help ensure that prostheses are matched to beneficiaries' needs and that (Medicare billing contractors) can assess the medical necessity of these devices," the report said.
Meanwhile, the rate of diabetes-related foot and leg amputations continues to fall, due to better patient care. Among the Medicare population, it declined 66 percent from 1996-2008, according to the Centers for Disease Control and Prevention.
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Online:
Avalere research: http://tinyurl.com/84g23lm
Medicare: http://www.medicare.gov
Health and Human Services inspector general's report: http://tinyurl.com/7pj4g9s
American Orthotic & Prosthetic Association: http://www.aopanet.org
Copyright 2012 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.
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