O&P: Failing To Protect ‘Qualified’ Status through Licensure?

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By Susi Funkhouser, MBA

Pursuant to the federal statute, Section 427 of BIPA 2000, a qualified practitioner is defined as: A physician, a qualified physical or qualified occupational therapist, and a state-licensed orthotist or prosthetist; or in states that do not issue those licenses, a trained individual who is either: (1) certified by either the American Board for Certification in Orthotics & Prosthetics (ABC) or the Board for Orthotist/Prosthetist Certification (BOC), or (2) is credentialed by a program that the US Secretary of Health & Human Services (HHS) determines, in conjunction with appropriate experts, has sufficient training and educational standards. The Negotiated Rulemaking (NRM/NegReg) Committee, which failed to reach consensus, was charged with assisting Health & Human Services (HHS) Secretary Tommy Thompson in implementing the legislation.

The O&P industry has been slow to embrace the need to define and regulate its own profession and, as a result, is now facing multiple issues of attempting to compete with unequally qualified O&P service providers for equal (or potentially greater) reimbursements. This type of regulatory process, demonstration projects for competitive bidding, or other attempts to regulate and control Medicare spending are not the place to fight the battle of clinical competence. It is necessary that this issue is resolved prior to any "pro-competitive measures" that rely on an equal playing field when it comes to quality of services provided.

Jim Kaiser, CP, POINT Health Centers NRM representative, recognized this early in the process. Kaiser recommended to the POINT Board of Directors that "POINT must encourage pursuit of state licensure for O&P in all states. This industry must unite in the common purpose of creating a universal standard of competence for O&P, or the patients/end-users/consumers of O&P services and we who proudly provide the services will be the ultimate losers."

Tony Barr, NRM Barr Foundation representative, agrees, "The fact remains that, due to our failure to reach consensus, in most states anyone--without regard to qualification--can still continue to provide O&P services and bill Medicare. Those unqualified, non-certified, non-licensed providers in 44 states can continue to bill Medicaid and private insurers. We failed to take an opportunity to stop this! As a consequence, 26 states are targeted to eliminate Medicaid benefits for O&P, and four states have already eliminated or drastically reduced their benefits for O&P."

Barr hopes the O&P industry will press CMS to enact a federal statute that addresses who is clinically qualified to provide O&P services: "From the prosthetic patient perspective, wouldn't more protection have been accomplished from adoption of legislation that established a federal standard for who is qualified to provide care, replacing the present zero regulation existing in 44 states?"