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Kencor

A question about costs

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Has anyone on the forum found a website that can give you an idea about what to expect costwise when you are wanting to get an upgrade to your prosthesis? (in the U.S.)

For example, I just got a "multi-axial" ankle and it has completely changed the quality of my life for the better. My insurance company is reluctant to pay for stuff like that since they are not really interested in the quality of my life so I am kind of wondering what to expect if they refuse.

The ankle looks like it is made up of parts that I could pick up at Home Depot for about $30, but I'm guessing it's going to be more than that.

I know the easy answer is to ask my prosthetist, but I would like to be able to research this myself and not have to pick up the phone and bother him whenever I come across something that looks interesting, such as the "perfect stride" foot, which I think I am going to have to have next.

Just wondering, and thanks in advance.

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I wish I could help you. I've been searching for several years on and off for such a website and have never found one. Earlier today I posted to one posting about how satisfied we are with our prosthetics. I'm sure we all realize our prosthetics are 10K USA $ and up. It is my firm belief that we as amputees deserve to see what our prosthetists have available and the price of the various parts in advance to getting a prosthesis. We wouldn't have our cars repaired without getting an estimate or anything else for that fact, so why can't we know what the parts of our prosthesis run. The medical field needs to get real with individuals, not just prosthetists. A lot of the blame goes to the health insurance organizations. I don't know about anyone else, but I got stuck with what was chosen for me and if it wasn't just right, they played with it to make it duable--unfortunately, I don't find mine to be duable, but I moved from one area of the country to another and am stuck with it. Good luck on your hunt and let us know how you make out.

Carole

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I think the prices are different cash vs insurance. If youe leg guy can write the statements to justify your foot that should be all you need. Just fight them.

My foot was very exspensive nand it has made all the differncein the world in my walk gait and balance.

I understand it was about 8,000.00

Skully Cat

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I''m going to take a swing at this, but, none of it is written in stone,anywhere, it is just my opinion..

As far as prosthetics go, ask your prosthetist about them. It is his job to explain what different prosthetics do, how they react, and if it is right for you..and as for cost, if he doesn't explain it with you, he can get the office person who is in charge of that portion of it. As with anything else, I suppose they have their opinions, but they have knowledge too..As for us, being the wearer, it's up to us to become knowledgable about the prosthetics we wear. As well as what our insurance company will and won't pay for.

Insurance companies class the prosthetics to your ability.. Why would someone who never has and is never going to run, need a running leg? Just to say they HAVE one? They make sure that they only pay for what works for you.(plus live to give us major headaches) Some pay for only one at a time, one in a lifetime (God forbid), and other's are more lenient and will pay more often. Not saying I agree with the insurance companies. Lord knows, I've had my share of arguments with them, but, knowing their "rules" has been a huge help to me in knowing, how to proceed, what I'm going to be paying out of pocket for the prosthetics that work for me, if anything. Also, sometimes, just explaining to your doctor, (who has to write a prescription for your prosthetic) that what you are wanting is needed for your activity level, will help. They don't usually understand the ins and outs of prosthetics, as we learn to.They don't really have to deal with them on a daily basis. Educate them, if needed.

We as patients, sometimes forget, and just take them,(as well as doctors) at their word without asking..

One thing I have learned, since my accident, (having 5 doctors, and a prosthetist, all at one time) is that I can say no. But, you have to be knowledgeable about what ever it is.

Does your prosthetist email? Mine will answer an email if I ask him a question. If he doesn't like what he is reading or is concerned, he will call instead of emailing me back. Is something like that a possibility?

I read the prosthetists magazine's will in his office. O&P Edge is a good one for learning about new prosthetics. You kind of have to be able to understand prosthetics though..

What about your prosthetics manufacturer? Ossur has a website.. browsing through it, can give me an idea if what I'm looking for in a foot will work or not. They class theirs by activity level, so it's easy to see if it for you or not. They place little activity class icons with each prosthesis. Try looking for the manufacture's website..They are usually pretty interesting and informative.

Hope that you have found at least one helpful suggestion in this long winded post.

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A lot of the blame goes to the health insurance organizations. I don't know about anyone else, but I got stuck with what was chosen for me and if it wasn't just right, they played with it to make it duable--unfortunately, I don't find mine to be duable, but I moved from one area of the country to another and am stuck with it. Good luck on your hunt and let us know how you make out.

Carole

Carole, why are you "stuck" with what you have? If it's not working you should be able to try something else.

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I think the prices are different cash vs insurance. If youe leg guy can write the statements to justify your foot that should be all you need. Just fight them.

My foot was very exspensive nand it has made all the differncein the world in my walk gait and balance.

I understand it was about 8,000.00

Skully Cat

'skully cat' I have talked w/BioQuest and they have sent me literature o the PerfectStrideII (which I believe is the new foot you have just received. I was told they are in the range of $2800-3000 price range. If it is possible I would like to see it before purchasing. I am so glad it has helped your walking and balance.

For me that says it all about a foot; other than I would want my foot and leg to be covered and look like a leg. :unsure: Guess that is a hang-up of mine. :)

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Ann, oddly enough, with my old prosthesis (hurt my shin each and every step!!), the foot did basically nothing... with my new leg (and I will post pics and an update soon), my foot rocks and rolls like I never knew was possible!!

It's ok to want the cosmesis... we are all different and we all want what we want. There's not a thing wrong with wanting the cosmetic covering.

Marilyn

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Ann, oddly enough, with my old prosthesis (hurt my shin each and every step!!), the foot did basically nothing... with my new leg (and I will post pics and an update soon), my foot rocks and rolls like I never knew was possible!!

It's ok to want the cosmesis... we are all different and we all want what we want. There's not a thing wrong with wanting the cosmetic covering.

Marilyn

'Marilyn' so glad you are happy w/ your new leg. What a great thing lady, to be able to walk without pain in each step. Can't wait to see it.

When you said you were crawling around working on your flowers,,,,did you have your leg on??? :rolleyes: Didn't it hurt like the dickens?

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Carole, why are you "stuck" with what you have? If it's not working you should be able to try something else.

--------------------

Marcia

I guess I'd say I'm stuck with it for a number of reasons. At first it seemed fine, but then I broke the hip of the same leg, the knee of the same leg was worsened by the fall, my husband was dx'd with stage 4 colon cancer, we move half way cross the country back home, and my husband passed away. By the time I got to a prosthetist where I'm at, all he was interested in doing was more tweeking my prosthesis because it was still in good condition and giving me new liners. The prosthesis was done through vocational rehab when I was planning to go back to work prior to my list of things above. I am on full disability for Crohn's Disease and get my widow's portion of S/S as well. I am on medicare and a supplemental and medicare dictates how often and for what reasons you may get a prosthesis. At this point, I haven't a clue as to what type of doctor in this area to go to to have my leg's situation accessed for a lighter prosthesis. The one I have really hurts my hip and lover back area. I don't seem to walk in my prosthese, but rather sling it ahead to walk because of it's weight. That's where I am at present with it. I just wish prosthetists would show us what's available so we have some decision input into the matter since we have to wear it.

Thanks for your reply, Marcia.

Carole

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Carole,

I am/was wearting the Ceterus LP foot and still had a lot of low back / hip pain from all of my injuries. Last September, I got the Elation foot for the office, and because the heel height changes it allows me to NOT wear shoes in the house, which helped me a bunch......I was really surprised at how much.. Maybe, there is a possibility of something like that...not so expensive. I would talk with who ever you are using for a family doctor for yourself and see if he will agree that it is medically necessary for you. That is the most important part of all of it...

I know that dealing with Medicare is no fun... also, if it comes down to it, there is the Tony Barr foundation... Maybe they can help......

Ask your CP to explain your choices and options.... it's your right, never be afraid to ask..

Pain is pain, no matter what.... and to get out of it, is a blessing.....

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Carole

If you are on medicare you need to have your medical doctor working with your prosthetist to justify the claim. Given the doctor can state the proper medical reasons medicare will have to ok the purchase unless the part you are replacing is rated for a activity level that you do not meet. Even then you can appeal your claim by providing more medical support. Go to a prosthetist and have him work with the doctor who provided the prescription.

Dave

Carole, why are you "stuck" with what you have? If it's not working you should be able to try something else.

--------------------

Marcia

I guess I'd say I'm stuck with it for a number of reasons. At first it seemed fine, but then I broke the hip of the same leg, the knee of the same leg was worsened by the fall, my husband was dx'd with stage 4 colon cancer, we move half way cross the country back home, and my husband passed away. By the time I got to a prosthetist where I'm at, all he was interested in doing was more tweeking my prosthesis because it was still in good condition and giving me new liners. The prosthesis was done through vocational rehab when I was planning to go back to work prior to my list of things above. I am on full disability for Crohn's Disease and get my widow's portion of S/S as well. I am on medicare and a supplemental and medicare dictates how often and for what reasons you may get a prosthesis. At this point, I haven't a clue as to what type of doctor in this area to go to to have my leg's situation accessed for a lighter prosthesis. The one I have really hurts my hip and lover back area. I don't seem to walk in my prosthese, but rather sling it ahead to walk because of it's weight. That's where I am at present with it. I just wish prosthetists would show us what's available so we have some decision input into the matter since we have to wear it.

Thanks for your reply, Marcia.

Carole

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If you are on medicare you need to have your medical doctor working with your prosthetist to justify the claim. Given the doctor can state the proper medical reasons medicare will have to ok the purchase unless the part you are replacing is rated for a activity level that you do not meet. Even then you can appeal your claim by providing more medical support. Go to a prosthetist and have him work with the doctor who provided the prescription.

Dave

Thank you for the information, Dave. Can the prescribing Dr. be one's primary dr., or does it have to be someone like an orthopedist or a vascular physician (my amputation was done by a vascular surgeon in another area of the country)?

Carole

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Your primary doctor is just fine.. Mine works with my CP.. I haven't seen my ortho since he released me after the accident, about 3 years ago.. Anyway, that's how it works for me.... I do try to keep my primary doctor "in the loop". The one thing that we will sometimes take for granted is the fact that our doctors "know" as much about us being an amputee as we do. That isn't always the case..

My orginial primary doctor moved to another state to go back to school for a field that he has always desired which left me dealing with a new one.. He hadn't dealt with any up to the point of my becoming a patient. (Unfortunately, in our area, I found that with a lot of doctors). Anyway, I try to make sure that he understands about the things that I need when my CP will contact him. Prosthetics are not something that he knows a lot about, and at least he is willing to work with me. Talk with him, and tell him what is going on, and how a new/different prosthetic will change your quality of life.. Usually, they don't deal with the billing for Medicare anyway, the billing department does. He may not know what you are up against...

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Higgy wa right on. In my case I have my orthopedic specialist handle the support. They have their own prosthetic department which I do not use anymore but they know exactly how the medicare forms need to be filled out. If you use your local doctor and he or she does not have experience in how the forms need to be filled out then either get your doctor to refer you to a specialist or have your doctor get the instructions for the paperwork from a competent prosthetist.

Good Luck

Dave

If you are on medicare you need to have your medical doctor working with your prosthetist to justify the claim. Given the doctor can state the proper medical reasons medicare will have to ok the purchase unless the part you are replacing is rated for a activity level that you do not meet. Even then you can appeal your claim by providing more medical support. Go to a prosthetist and have him work with the doctor who provided the prescription.

Dave

Thank you for the information, Dave. Can the prescribing Dr. be one's primary dr., or does it have to be someone like an orthopedist or a vascular physician (my amputation was done by a vascular surgeon in another area of the country)?

Carole

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My family doctor will write a "prescription" for whatever I need stating the reason. For instance, in December I got a Silhouette foot. The doctor wrote the prescription stating that since my activity level had increased I needed a lighter foot that would aid me in being more active. The insurance company didn't question it. I would imagine Medicare would be the same. In your case, you might need the dr to state that your present prosthesis is too heavy and you are unable to walk in it.

Good luck.

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Thanks to everyone for the help. I've learned the way they do things in one area of the country can be totally different in another. It becomes disheartening to know one needs something new in the prosthectic area and not know who to go to in order to get it done. Guess I'll start with my primary care dr. and go from there. I've been going to him about a year now so hopefully he knows me well enough. What makes it hard is that cousins and the such seem to think I should be getting around better than I am, but they have no idea what all is involved. It's just not like buying a pair of shoes in the store and knowing what these things cost also makes it a bit scarey because someone else is paying for it (hopefully, anyway). Ya'll cut through that with a simple answer and I am grateful.

Carole

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