In order for a patient to be eligible for Medicare’s Therapeutic Shoe Program, a physician (MD or DO) must certify that the patient has diabetes mellitus, that the patient is being treated under a comprehensive plan of care for diabetes, and that it would be medically necessary for the diabetic patient to have therapeutic diabetic shoes.
The MD or DO physician who is treating the patient’s systemic diabetes condition must currently also certify that the patient qualifies at least one of six lower extremity conditional findings for diabetic shoes/inserts eligibility:
In practice, a podiatrist―a Doctor of Podiatric Medicine (DPM)―or an orthopedist, is the one who performs the patient’s detailed lower extremity examination qualifying at least one of these six conditional findings. In doing so, it is the podiatrist who typically identifies medical necessity (and writes the prescription/order for diabetic shoes/inserts) and initiates contact with and reports requisite information to the patient’s physician (i.e., the certifying MD/DO).
Podiatrists and orthopedists are finding that their medical records, which contain more detailed lower extremity examination findings than the MD/DO’s records, are either being discounted or completely ignored by the DME Medicare Administrative Contractors (DMACs), Contractor Medical Directors, and auditors when making a case for qualifying their patient for the therapeutic shoe and insert benefit. Refunds are being asked from the suppliers (both podiatrist-suppliers and commercial suppliers). Recent rates of audit claims error/denials are alarmingly high. Some recent reviews reveal 85–97 percent of the audited claim submissions are being denied by regulators and auditors who have been following narrow DMAC Local Coverage Determination policies. (APMA has received anecdotal evidence that a large number of these decisions are being overturned “favorably” by Administrative Law Judges.)
For several years, APMA has discussed these problems with CMS and the DMACs, and while they are sympathetic they have said that any remedy must come from a statutory change.
APMA members are becoming increasingly frustrated with this status quo, with a number now dropping their participation in the Medicare Diabetic Shoe Program and many others considering no longer serving as suppliers. The anticipated consequences include reduced or progressively difficult access to this medically necessary and appropriate benefit for diabetic patients. The passage of HR 1221/S 626, the Helping Ensure Life- and Limb-Saving Access to Podiatric Physicians (HELLPP) Act, would alleviate this problem.
APMA has identified some minor balanced improvements to clarify provider roles and remove confusion and regulatory inconsistencies in the provision of this medically necessary benefit. These clarifications would preserve the integrity of the checks and balances in the diabetic shoe/insert program. MDs or DOs who are treating the patient’s diabetes would certify that the patient is under a comprehensive program of management of the disease; podiatrists/orthopedists would determine medical necessity for diabetic therapeutic shoes and inserts and prescribe those shoes and inserts; suppliers would fit, provide, and evaluate fit of the shoes and inserts. Under this proposal, the roles of the MD, DO, and DPM would, however, be clarified, thereby strengthening their coordination of care and communication in treating Medicare diabetic patients.
This targeted reform would amend § 1861(s)(12) of the Social Security Act to clarify roles and improve communications among medical providers. It will significantly reduce the frustrations of the physicians and suppliers over the current administrative policies of the Medicare Diabetic Shoe Program, help ensure that those Medicare patients who are most at risk and eligible for this benefit receive it, and obviate Medicare diabetic patients making additional office visits, which in turn would save money for patients/beneficiaries and the Medicare program.
Download this issue/policy brief: Diabetic Shoe Program Issue Brief (PDF)