Therapeutic Shoe Claims and Poor Reimbursement

Several DPMs have been posting questions on what to do about $6 profit margins on therapeutic shoe claims by several Medicare Disadvantage plans. The answer sadly for your patients is to write a script and send the patient out. Your ROI is far less than the $6 many shoe provider’s quote for Part C patient. The time your practice needs to obtain pre-determination of benefits/prior authorization and other peripheral paperwork required to obtain the shoes, etc. leaves most practices at a loss when it comes to providing this service. Hence, in many areas of the country there are either only a few or no providers willing to continue to participate in this program. And that is for all insurance programs.

This issue has become a lightning rod even for traditional fee for service Medicare. The DME MAC Medical Directors are all acutely aware of this issue and have asked me numerous times where the problem is. By now you already know that I have told them to look in the mirror.

Patients are suffering and the statistics show it. The Part B-BMAD data shows a significant decline in therapeutic shoe claims for traditional Medicare. There are many stories from provides displeased with how Aetna, Humana, and other Part C plans are reimbursing. Thus the decrease in therapeutic shoes for Medicare Part C beneficiaries has now also crossed over to both traditional fee for service and Part C plans. From a policy perspective, the fee for service directors are claiming that it’s CMS’s fault and they want this to go away. However, none of the DME MAC CMD have been willing to fight for change. Congress, well you can forget about that for now. And the Part C carriers are purely profit driven and totally corrupt.

Where are the two organizations that represent the largest contingent of diabetic patients? The ADA and AARP have not been willing to get into this fight. This preventative program can save countless limbs for patients who cannot afford to purchase appropriate footwear on their own. So much for Medicare being the gold standard of insurance plans and a plan to serve all the people, no matter what their economic stature.

From a personal perspective, I know that APMA and other medical associations have met with the DME MAC and CMS on numerous occasions. Nothing remotely responsible has been done. The DME MAC medical directors want this problem to go away. The audits that CMS has sanctioned on them cost the carriers money too. So far nothing has remotely come close to solving this problem. 

The solution is for Congress to modernize the program. Allow DPMs to certify the medical necessity and simply obtain a copy of the patient’s medical record from whatever provider is treating the patient’s diabetes. There is no need to have one physician in a different specialty sign off on another specialist’s notes. Especially when they have not examined that body part or have little if any knowledge of that anatomical site. That is contrary to good patient care and that is why we are in this mess now. CMS needs to clean this up and do it soon. We should soon have a good idea, as the Part B Data comes out for 2024 on shoe claims versus ulcer debridement, CTP applications, etc. It’s likely those will continue to rise in both Part B and C. Hopefully another disenfranchised patient does not lose their limb because of the stubbornness of CMS and Congress to change this current policy.

—Paul Kesselman, DPM (Park DPM Consulting, LLC)