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Medicare rule affects voice box patients

Updated: September 24, 2012 6:25AM

A change in Medicare reimbursement for a prosthetic device that allows people who have had their voice box removed to speak has led some providers to stop offering the device or reducing the number of patients they see.

The change has to do with how Medicare reimburses for a device called tracheo-esophageal voice prosthesis, or TEP. The device facilitates speech for laryngectomy patients who have had surgery to remove their voice box, usually because of cancer. It must be replaced roughly two to four times a year.

In the past, Medicare partially reimbursed patients who purchased TEP devices at full price from the manufacturer before having them inserted by a doctor. Now, since Oct. 1, Medicare covers only devices that have been purchased by health-care providers.

Providers say the problem is that the amount Medicare reimburses them per device is far less than the invoice price they pay.

The Bastian Voice Institute in Downers Grove closed its laryngectomy program last month because it could no longer absorb the cost of providing TEP for its 60 laryngectomy patients.

“It’s exactly as if every patient who walks in here for this service, I hand them a $100 bill on the way out,” said Dr. Robert W. Bastian, who added that he is exploring a way to reopen the program.

Advocate Lutheran General Hospital in Park Ridge still offers TEP and said the rule change hasn’t had much impact because patient volume is low. But if, as in past years, the hospital were treating 50 to 60 laryngectomy patients at a time, covering that expense would be difficult, said Carolyn Walton, director of rehabilitation, behavioral, neuroscience and senior services at Lutheran General.

The American Speech-Language-Hearing Association, which represents audiologists and speech-language pathologists, has also received reports of practices closing TEP programs or cutting down on the number of laryngectomy patients they see because of the change.

“You’re reducing the accessibility of the devices when practices are losing money every time they use it,” said Mark Kander, the association’s director of health-care regulatory analysis. “I’ve heard complaints from practitioners all over the country.”

Kander said there were no safety issues associated with having patients buy their own prosthetics, since a doctor would need to insert the device anyway.

But Joel Kaiser of the Centers for Medicare and Medicaid Services stressed that the Medicare rule merely reinforces a policy that has been in place but not always followed for TEP devices since 1993.

“We had a long-standing policy that says we don’t pay for something up until the time it’s inserted,” Kaiser said. “If you’re not the entity that’s providing the service, you shouldn’t be billing Medicare for that service.”

The only people affected by the change are providers who had “special arrangements” with device manufacturers to have them bill Medicare on patients’ behalf, Kaiser said.

“For everybody else who’s been doing this right for all these years, we haven’t heard from them,” he said.

As the speech-language association and other groups try to lobby CMS for other solutions, laryngectomy patients like Dorothy Ziga of Schererville, Ind., worry about having fewer options the next time their voice prosthetic breaks down. Ziga, 71, described not being able to speak, even temporarily, as “the most horrific thing you could imagine.”

“I can’t imagine ever not talking again, and I know thousands of people who are just like me,” Ziga said.

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