The ADA Act and I have walked on a lot of prosthetic knees . . .

All prosthetic knees are not created equal, and you have to WALK on them to know the difference. That puts "two legged people" out in the cold as being able to make decisions or tell an above knee amputee ANYTHING about what "might" work best for them. I have walked on a Century 2000, a Geoflex knee, an Otto Bock 3r60, an Otto Bock 3r80, an Otto Bock safety knee, a DAW auto Pilot - aka the SLK, a DAW standard non intelligent four bar knee, an Ossur Ultimate Knee, a C-leg and I currently have an Adaptive 2. I have used an "amputee solution" cushion shock and torsion adapter - no longer made I beleive. Really nice product. Two legged people come up with lot of reasons - most surrounding "cost" to try to deny an amputee the right to return to mobility under their own power and in comfort. Of course they get up every day and walk with two legs - without thinking about it. It is not "cheap" to build a good working comfortable AK or BK prosthetic, and worse most doctors do not have a clue how to prescribe one. Sure they can write prescription on a pad like any other "order" to a lower level medical professional like a pharmacist or prostheticist to fill, but they do not know how to write a prosthetic prescription and why to order that part, what series of parts or socket type be built. Rather than reproduce much of the language here, I will just provide the link to Chapter 29 of the Atlas of Limb prosthetics: Surgical, prosthetic, and Rehabilitation Principles. Rosemont, IL, American Academy of Orthopedic Surgeons, edition 2, 1992, reprinted 2002 found on the internet at http://www.oandplibrary.org/alp/chap29-01.asp to show you what I mean. It is written by an MD. However, because technology in prosthetic knees is changing so rapidly, no one can keep up. Along with the technological issues of prosthetic knees - come the physical question of whether the knee will fit in accord the HEIGHT it will consume with your foot; if it is compatible according to the manufacturer, and any intermediate part in between like a torsion adapter. prostheticists are only going to be concerned with billing - what they can bill the insurance carrier for and get paid. Many will drop you if they cannot bill - or you cannot pay what they feel they should have the right to charge. There is a major law which prevents this - the ADA Act - however the sad reality is to gain enforcement you have to sue in Federal Court under a "novel" argument and well structured legal "trap". You find it in the Americans with Disabilities Act starting under "discrimination" at 42 USC 12181 at "Definitions"; where 7 E and F define a public "accommodation" to include "sales or rental establishment" at "E" and a "professional office of a health care provider, hospital, or other service establishment" at "F". This is critical to the next component in the law - "discrimination" where 42 USC 12182, at "(a)" and then again more specifically at (b)(1)(A)(2)(i), the law prohibits "the imposition or application of eligibility criteria that screen out or tend to screen out an individual with a disability or any class of individuals with disabilities from fully and equally enjoying any goods, services . . ." and this is where Medical professionals and DME vendors can be sued for refusing what you seek as a prosthetic component or set of components. If you are in any form of "managed care" - you already know what I mean. The trouble is - you need to get a prescription first - or be prepared to prove the doctor refused you such services of writing the prescription for a REASON OTHER than medical. This is the "managed care trap", they prevent you from even getting the prescription to have the right to get the "goods" or "services". Hmmmm. . . Once you have a prescription, whatever it says commands the rest of the troops - whether they like it or not. AND you must be able to of course pay, or have insurance that should pay. Now nothing at this point prevents you from bargaining for the best price - if you have a typically steep 20% co-pay on prosthetic items. Otto Bock built an entire program around their C-Leg which encompasses the cleavat of section "(i)" which reads ". . . unless such criteria can be shown to be necessary for the provision of the goods, services, facilities, privileges, advantages, or accommodations being offered; . . . " Here they manifest their entire Otto Bock certified prostheticist program and / to exclusion of all others not so certified by them to maintain the quality of the product and sanity and safety of their reputation as a company and with GOOD reason. This is why the C-Leg just plain works great. BUT . . . this does not protect insurance companies and entities - even government entities like Medicaid bean counters; which is a program administered by the States - and each state may have its own name for the program which include "Medi-Cal" in California, "MassHealth" in Massachusetts, "Oregon Health Plan" in Oregon, and "TennCare" in Tennessee, who deny coverage based on dollars. The process for building a case to file in Federal Court is a bit complex depending on where you are, but normally you must exhaust the state remedies arguing Federal rights all the way - claiming discrimination in accommodations to give a Federal court solid lasting jurisdiction to hear the complete case. If you do not - the Federal court may dismiss the matter as premature because you did not follow channels or have state law issues not proper in the Federal court. Of course the real problem is - finding a competent attorney who knows how this species of law works. You cannot confuse cost with rights. You must have a prescription speaking to medical necessity first from a physician and then you can move forward. For instance, Otto Bock has a pre-requisite that you must have walked on a Hydraulic knee previously before seeking a C-leg. While they are not enforcing this as much as they once did, (if physical therapy is included for instance to teach you how) it does fit the cleavat clause above for both cost and need. In my particular case, a State agency allowed fraudulent billing by a major national prosthetic house and then when fraud was alleged by me - they said "so what" - but now that I needed more services - the excuse they must use will not now hold up in Federal Court if I am denied. Allowing and paying for fraudulent services but not wanting to pay for genuine; honest medical necessity services of need will not hold up well under the law or in court. Many people do not realize the US Supreme Court issued a major ruling which bolstered the ADA Act as a powerful law which also then turned into Presidential Executive Order 13217. OLMSTEAD V. L. C. (98-536) 527 U.S. 581 (1999) 138 F.3d 893, affirmed in part, vacated in part, and remanded, was a case that decided that Disabled individuals under the power of the ADA Act have the right to decide their fate or services be rendered to "an individual with a disability in the most integrated setting appropriate to the needs of the individual." This is language straight from the ADA Act the US Supreme Court completely adopted. While Olmstead involved the issue of what we would call "mental patients", it struck a blow to government entities everywhere that they could NOT deny and decide in a "we knew best attitude"; which then includes "managed care" and other terms used for institutionalizing treatment of persons with disabilities. President George W. Bush expanded it somewhat in Executive Order 13217. Now you can believe any person with "two good legs" has very little clue or respect for the ADA Act beyond knowing it exists, but it is an expensive and powerful legal trap for their hard heads if used right. Today we have a new national "Health Care law"; but the reality that bean counters still exist with two good legs - and when they discover just one replacement part for a prosthetic costs thousands of dollars and denies a claim based on that needs to be hit with ADA Act suits more often. Their attitude is better them than me and deny a claim and stand up and walk to their car and go home and eat dinner. The first thing you do - is go into the process not trusting anyone will do the right thing to help you and trap them first in their conscience and then in their stupidity when they try to squirm you out of what you need because it is their job to do so. Then proceed to Federal Court armed with the ADA Act hollering what the law provides above on "good paper" embarrassing that hard head jerk. At the very least they will be slightly ashamed and never forget you. At best you find a Judge truly disgusted and they will REALLY never forget you when you win big time. So yes, I have walked on a lot of prosthetic legs, and the better they are the more expensive they are and more ugly little toad bean counters like this pop up hiding behind the "Erkel" . . . "ooopppss . . . did I do that" defense. The C-leg is just the best leg out there right now - but it is so damn expensive to get and maintain, the next best is the Adaptive from Endolite; but it blows hydraulic cylinders, and it so bad they make the cylinder a "field replaceable unit"; and so and I'll keep you posted on how this turns out - because Endolite and the State right now are both acting like - well - "two legged people" with "S__T for brains. Stay tuned.
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