But these warnings did not stop him. In January 1998, Miguelez, who received his training in prosthetics at Northwestern University, launched Advanced Ann Dynamics, Inc., (AAD) from his home base in Rolling Hills Estates, Calif.

In the beginning, AAD was just two people: Miguelez, now 37, and his wife, Caro, who is chief financial officer.

Today, AAD is growing. Additions to the staff include patient coordinator Kristie Curtis, herself a below elbow amputee who is based in Dallas, Texas, and a second practitioner, Jim Mumm, CP, who is based in Omaha, Neb. Miguelez is planning to hire another prosthetist as well.

The growth of AAD hasn't been in a straight line. Miguelez has had to adapt and add sills beyond just fitting limbs to make his practice work.

His friends proved to be correct to some extent when they warned him about the protectiveness of other practitioners. Some don't want to split fees, he found, and others are afraid patients will see it as a weakness if they bring in a specialist.

To make himself attractive to O&P caregivers, Miguelez established teaching alliances with a number of major manufacturers of upper limb devices. He writes and presents frequent papers on upper limb techniques. He has established ties with case managers at a number of prominent HMOs and insurance companies. And, he has established a detailed and active Web site where patients can contact him them- selves.

Recently, he signed on as a senior vice president and senior clinical director for Rehab Designs of America (RDA), headquartered in Kansas City, Mo. RDA has 70 sites across the country, and Miguelez runs seminars and helps manage upper limb cases at all of the locations. "I didn't want any grass growing under my feet," he said of this move.

Perhaps the most unusual step Miguelez has taken to make himself attractive as a traveling specialist for other practitioners, however, has been his guarantee-in writing-- that practitioners who call him in on a case will be reimbursed.

"As the son of an attorney, I had to negotiate and plead my case at the dinner table growing up," he said. "I've become very good at it."

Miguelez estimates that the average authorizations rate for most upper limb patients is around 43 percent. But his is much higher. "We run about a 94 percent success rate," he said.

Rule number one in negotiating with payers is not to anger them or try to trick them, he says. Instead, Miguelez leads payers through a step-by-step "courtroom" presentation of how using him to help their patients will save them money.

This isn't some fast-talking sales pitch, he stresses. Each case is presented in detail. Payers are shown how the investments they make in replacement upper limbs will save them patient care money in the long term. "We have a payer protocol, and we're very efficient in how we provide care to the patient," he said. "There's not a lot of redo's and refabrications, so the patient is back to work or back to the activities of daily living in the shortest time possible. That's what leads to our success rate."

Miguelez sees no patients in a practice of his own. He doesn't have one. All of his work is done at other facilities. "I specialize in one area, and I go to the patient," he emphasized. "Our company is a company without walls."

For simpler cases, he may be able to assist practitioners to a successful conclusion by using digital imagery and working over the Internet. But mostly, Miguelez is called on to help with difficult cases, and he goes to the originating practitioner's site.

"We do expedited fittings," he said. "We might spend three to five days."

Miguelez works frequently with the central fabrication department of Otto Bock, whose techniques he likes. He may do a fitting, then return to California to do the fabrication, then return to fit the patient and begin the rehab instruction. Through it all, he is extremely protective of the initiating practitioner.

"The patient always remains the facility's," he said. "If the patient calls us six months later and says 'We'd rather work with you,' we don't do that. AAD is the practitioner's safety net that can provide education and componentry that really allows the patient to excel."

Miguelez says AAD may consult on 1,000 patients per year, but probably actively handles 200 to 250 cases per year. There is no "typical" patient, but Miguelez handles more than his share of child cases and bilateral upper limb amputees. He uses the most up-to-date myo-electrics when possible and relies on techniques such as the immediate post-operative prosthesis (IPOP) to get patients quickly thinking rehabilitation.

He says few AAD patients become "arm-in-the-closet" non-users of replacement limbs. "We're running about a 94 percent success rate," he said. "I believe most patients want their arm back. A lot of it is practical, but a lot of it is also cosmetic."

Once practitioners have over- come their anxieties about bringing an outsider in, they will often call AAD on additional cases, Miguelez reported. He's proud that he's con- firmed the need for an upper limb consultancy in O&P through the success of AAD.

"We are definitely unique in the industry," he said.