Stepping Forward: Understanding Prosthetics and Orthotics – Part Three: Insurance Basics, Medicare 101, Inspiring Stories, and Next Steps!

In the final installment of our three-part series, we’re joined once again by Jason Auyer to bring everything together. This episode covers the essentials of insurance and Medicare—what you need to know to get started and advocate for yourself. We also take a moment to reflect on uplifting patient stories that highlight resilience and hope! Whether you're beginning your journey or supporting someone who is, we wrap up with practical advice and next steps to help you move forward with confidence! 

Part 1: https://www.buzzsprout.com/2397060/episodes/17118158

Part 2: https://www.buzzsprout.com/2397060/episodes/17175062

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Guest: Jason Auyer, LCPO, Owner of Alliance Prosthetics and Orthotics

Host: Rachael Auyer, Co-Owner of Alliance Prosthetics and Orthotics

Producer: Laine Johnson, Alliance Prosthetics and Orthotics, Marketing Assistant 

Transcript

SPEAKER_00 0:03

On today's episode, we are concluding our three-part series, Stepping Forward, Understanding Prosthetics and Orthotics. If you miss part one and part two, stop the podcast. You want to go back, make sure you're caught up. Today we're going to cover insurance basics and Medicare 101. At the conclusion of the podcast, we'll have inspiring stories and next steps. We're so glad you're here. Insurance 101 basics, we can't cover comprehensively today what patients need to know about their insurance. But overall, if you could give a patient some insight, what do they need to know and what are some really big issues you have seen?

SPEAKER_01 0:47

Sure. I think globally when we look at the uh insurance here in the United States and how all that works, is it the best? No. Is it the worst? No. There is access to care that we have in the U.S. that you're not going to have other places. Sometimes it can be very frustrating with how long it can take, or at times things that get denied. So a few different things that I would say, and this is could be for parents, this could be for patients themselves, is know your plan. Be an advocate for yourself. You're going to be no one is going to advocate better for your child or for you than you. And so reach out to your insurance company, understand your policy of how it works. Also be able to partner with an orthotic and prosthetic clinic that is willing to fight for you. Because how insurance works is that they are going to pay their portion of that orthotic or prosthetic device, depending on how your plan is set up. So you could have a deductible, and that deductible you would have to pay before your insurance does anything. And so you want to see, does that deductible apply specifically to orthotics and prosthetics? And we fall within what's called the durable medical equipment. So if you were to call your insurance company and say, hey, what's my deductible for DME or durable medical equipment? And then say it's a$500 deductible, but the device that we're going to provide is$1,000. So that first$500 you're having to pay before your insurance does anything. And then from there, they're going to go through and they might say it's an 80-20 plan or a 90-10 plan. And all that means is after you've met your deductible, your insurance is going to pay 80%, right? And then you have to pay 20% up to what's called your out-of-pocket max. And I know there's a lot of different terminology and things to know and remember. But with besides all that, talk to your, this could be your medical provider, it could be your primary care physician, pediatrician, your orthotic and prosthetic clinician, their office. Help them to explain to you how your insurance works, and then call your insurance and be an advocate to make sure that you understand as well.

SPEAKER_00 3:04

Thank you. I know that we're going to have to revisit this because there's just too much. But I was thinking about our Medicare patients. You know how complicated it can be at times because there's different avenues patients can use and policies and so many acronyms. Can you just quickly touch on what Medicare patients need to know?

SPEAKER_01 3:25

Sure. So Medicare, if you are over 65, you're going to be eligible for Medicare. There's other situations that you can be eligible, but that's the main one. As soon as you're eligible for Medicare, probably a year or two before, you're going to get so many things in the mail, so many emails, so many calls, because it's not just normal Medicare. You could also have what's called a Medicare replacement plan. What that means is there's another insurance company, it could be Blue Cross Shield, could be Aetna, could be United Healthcare, it could be Humana. There's so many, Cygna, there's so many different ones, that they are going to administer your Medicare dollars. Okay. The other thing, so you got Medicare, Medicare replacement plans, and then you can also have a secondary, a Medicare secondary payer. Okay. What the secondary is going to do is they're going to pay what Medicare doesn't. So if I were to all of our patients, if I could say, hey, if you're a Medicare patient, what should you do? What policy should you get? And this is sp speaking specifically to orthotics and prosthetics, but I've spoken with doctors too, and they they say the same thing, what I'm saying here, is get straight Medicare, okay? It's the card with the blue and red stripes over there, okay? And then get a Medicare secondary or supplement plan. That could be Mutual of Omaha, that could be AARP. There's a lot of different ones. The reason why is twofold. One, once you've met your Medicare deductible, which is usually somewhere in the two to three hundred dollar range, the rest of what you're responsible for, orthotics and prosthetics, is going to be completely covered. Okay? Once you get authorization for any of these devices, it's going to be completely covered. The other thing is sometimes some of these Medicare replacement plans, they will change the game. They will add other restrictions on what you can receive from your healthcare professional, and it can restrict the access to care that you need. And again, when they sell these plans to you, they're not going through and saying, hey, yes, you get this extra amount here to be able to exercise and go to the gym. But if you need a prosthesis, we're not going to cover this for you. They don't go through and explain those things. So again, just like I said earlier, know your plan, call them. If you know you're an amputee, you need to call your Medicare provider before you decide on any plan and ask them, how would you cover these devices? Go to your ortho orthodist and prostitutes, get a printout of some of the different codes that they use to bill, and you can go directly to your insurance company. Hey, how would you bill these? What what um what restrictions do you have? Um, how do you determine medical necessity for these devices? And again, you're going to be the best advocate for yourself.

SPEAKER_00 6:18

Thank you. I know that is a very complicated and heavy conversation. So I was hoping we could transition to the fun thing. The fun thing is patient stories. And so totally HIPAA compliant, no patient identifiers. We need some inspiring stories to digest the insurance stuff because we all are very sad about insurance. We're so glad we have it. Yes. But also, can you tell us what are one-to-two stories that stand out to you as when a patient was fit with a medically appropriate device, you saw a transition in that patient physically, emotionally. Um, obviously we're gonna talk spiritually too, because we think people are not just one dimension here.

SPEAKER_01 7:02

Mm-hmm. Mm-hmm. No, I'm I'm glad you brought that up. And that's why uh when we look at our mission statement, our mission statement talks about that everyone has inherent value and worth. Uh, and the reason we say that is because we believe everyone was made in God's image. And so the the spiritual component is that just because you have lost a limb, so have limb loss or limb difference on the orthotic side uh does not mean you don't have value. It does not mean you don't have worth. That has been stamped and impressed on you by your creator from the moment that you were born. The moment you were conceived, you have that. And so I love that you brought that up as far as the spiritual uh component there, as far as some stories um of of life change. And when I tell these stories, this is not giving Jason a pat on the back. This is trying to highlight our patience and what they've accomplished. We got to be a small part of it. They did the heavy lifting. First one I've been thinking about for a while as we've been going through our conversation here, uh, is uh a little girl in her wheelchair most of the time, uh, as part of a family that we treat multiple kiddos as a part of this family. Uh she was told by her doctor, the mother was told uh by their doctor that she would never walk. Now, I don't think the doctor was trying to be mean, I don't think anything, I think he was trying to be realistic of the likelihood that she would be able to walk. When I started to work with her, she was in her wheelchair uh almost the majority of the time, would go in something called a standard uh to help with stretching and weight bearing through the legs, and we would make some um they're called AFOs or ankle foot orthosis uh for her to help with standing and stability. We then provided this uh we're gonna do do some acronyms here, an HKAFO, all right, a hypne-ankle foot orthosis. Uh anyway, uh to help again that much more with standing and to try and weight bear a little bit on her own. Then she started progress with therapy and did a little bit more and did a little bit more and then finally her mom comes in and shows me this video of her standing up for the first time without holding on to anything and able to take a step. And you see these stories and Rachel knows this about me, I'm a glass half full person, I'm the eternal optimist for sure. But you see these stories and you're like, how could I ever tell a patient again there's no way that this is never gonna happen, that you're always gonna be like this. How could I say that to a patient when I literally before my eyes saw that patient who was never supposed to stand, who was never supposed to walk, stand up and take steps for the first time. That's on the orthotic side. I'll tell a brief story of someone on the prosthetic side or an amputee that that we have worked with. This individual, the first time I saw her in her patient room, um, most most of the time, you know, people in the hospital gown and you know, just had you know amputation and I mean a lot going on. She was all dialed up. I mean, she was she was wearing her makeup on and hair all done. And I I walked in there and there was more food and uh balloons and flowers, and I mean it was I could barely like get through. I had to swim through to get here. And so the first conversation I had with her, she said, Jason, I've been thinking about this. And she had just gone through tragedy. She lost her leg tragically in an accident. And I had the amputation, you know, days before. She had I've been thinking about it. I want three different types of prostheses. I want one for my everyday walking around. I want one because I like to wear high heels. I, you know, I go to different events, I need to be looking good, I need to be able to wear high heels, and I love to ride horses, so I'm going to be riding horses. So I need three different prostheses. This is what you know she was she was thinking. And so we we go through and we we start the process and we get her fit with her first prosthesis. Um and she's starting to learn to walk and and moving around. And the what's to me what's so amazing, a lot of things amazing about this individual. When I fit her, she was 79 years old. 79 years old, wanting to ride a horse. I I'm a little nervous, I'm 41, I'm a little nervous getting on a horse, right? She's wanting to get out a horse. And so sometimes patients, they come in with all these goals. And then we have we pair back a little bit. Not because they're not great goals, but we want them to be realistic. And we want patients to get traction and start moving forward. She very quickly is learning to walk on her own. Um, within the first three months, she had an event and she wanted to wear heels for this event. And so she came in and brought her heels. I adjusted the prosthetic foot. Could she walk for days in these heels? No. But could she walk at the event, come alongside, and hold onto her husband's arm as she was walking? Absolutely. And then, so that's the you know, the first two, and then she wanted to ride this horse, right? And so we're thinking, all right, we might have to do a different type of prosthesis, all these different things. Um, we I met her at her barn, at the barn with the horses. Um, the horse, because the horse has released hippotomy, the horse's name is Cash, so I can say the horse's name over the air here. Um, but gets up on on this horse and is riding around. This is within the first five to six months of being fit with a prosthesis. I don't say that to say every patient in six months is gonna get up, ride a horse. I'm not saying that. The reason I tell this story is that if you are dedicated to go after a goal and you're putting them the work to go towards it, we're gonna partner with you and work as hard as we can too. And when those things come together, there's amazing things that can be accomplished. And so again, getting back to can I tell a patient no, that there's no way that's ever gonna happen. Another quick little I I could tell my own stories. I'll tell this last one. Another patient on the opposite extreme um lost her leg below uh above her knee and first came in for a prosthesis, was not able to stand up on her own, even with two or three of us, we could not hold her up to stand on her own. So I told her, unfortunately, right now you're not a prosthetic candidate because the prosthesis is not gonna stand up for you. Okay? And so we said, we want you to go to therapy, um, and we're gonna have you come back in six weeks to our amputee clinic that we uh that we do with um Longstreet Physical Medicine and Rehab uh in Gainesville. She came back in six weeks, and I'm all ready to, okay, we're gonna try again, I'm gonna grab on and we're gonna try and stand up, and she just popped right up. I barely had to help her. She worked diligently over six weeks because she wanted a prosthesis so she could stand up again. And when we fit her with a prosthesis, not only did she stand up, she walked down the parallel bars, which is about ten feet. This is the individual who could not stand on her own, set a goal, was determined to go after it, was able to be fit with a prosthesis, and then blew us away even more and walked the first day that she had it on. And so are things impossible? No, are they hard? Yeah, they're hard. But is there hope and mobility? A hundred percent.

SPEAKER_00 14:12

I love those two stories because it shows both sides of the coin. So in healthcare, we at our clinic don't want to tell a patient it's never possible on the same situation. We also don't want to inhibit a patient. If they have a dream and a mission and a vision for themselves, we're gonna partner with them and help them get there. And we always talk about easy plus one. That's our mantra. We stole it from our kids' homeschool curriculum, so I want to give credit where credit is due. But easy plus one. What I wanted to ask, we've got listeners now on our podcast, which is pretty wild. Uh there's somebody out there who wants to know what's my next step. We've talked about so many different things, and this is a multi-series podcast. So we're gonna sum it all up. What do people need to do next?

SPEAKER_01 15:04

So I think what people need to do next is that they need to, with all this information that you receive, you know, talk about different types of orthotic devices and prosthetic devices and how insurance works and um um all all these different things, right? But I think what the next step is that if you feel like as we've been talking, like you know what, I feel like I resonate with one of these categories. I think there may be something that could be helpful for me. Is the simple next step is just making a call. If you are here um in the Northeast Georgia area, reach out to Alliance Prosthetics Northotics. Give us a call. 770-679-3090. Give us a call just to set up an initial consultation. Maybe you come in and we say, you know what, I don't know if there's anything that we can help you with. But you know what? I think we have an idea of someone else who might be able to help. Again, you should not live life alone going through this. Anything. Life in general, you don't want to live life alone. Bring people in. We talk about loads and burdens. All of us have our own load to carry, but burdens weigh us down. When we have a burden, we need other people to come alongside and help us to lift this burden. Don't hold on to this and feel that you need to do it on your own. Bring other people in. If you're outside of the you know, Northeast Georgia area. One, we'd be helpful to connect you with a spot. Um, but you know, look up and you can find this um the American Board for Certification for Prosthetis and orthodists. If you Google that, you'll you'll find there's a way you can Careful with the spelling. Careful with the spelling. That's right. Remember, prosthetics, prosthetics, right? Um, but you'll be able to find an ABC certified or accredited location in your area that they've gone through all the steps to make sure that patient care is at the utmost for them. Um, and uh that would kind of be your next step.

SPEAKER_00 16:58

Thank you so much for all the time you have given my me, your wife, your favorite uh podcast host, right?

SPEAKER_01 17:04

Favorite one.

SPEAKER_00 17:05

Favorite one. And also all of our listeners, we know that you are heavy into patient care, training young clinicians. You carry a lot of different hats, wear them all very well. I just wanted to say thank you personally for taking the time to educate us and make sure patients who are considering considering prosthetics and orthotics, I'm gonna say that again, considering prosthetics and orthotics devices or not quite sure about their uses, you gave a very comprehensive, but we could understand the regular people like me could understand what is it and why would I need it. So thank you.

SPEAKER_01 17:42

No, you're you're more than welcome. And again, our our hope and our goal is that we come alongside patients and take something that is very challenging, very hard, something that we wouldn't wish on anyone, and make it just a little bit easier. And it's kind of coming back to that loads and burdens analogy. This is a burden. Let us come alongside and help to carry that burden.

SPEAKER_00 18:04

Thank you. Were you inspired or challenged today? If so, connect with us. Follow the links in the description box below. We want to hear from you. Until next time, thanks for listening to the Alliance Goldigger podcast.