Fighting for the O&P Space

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By Kevin Hines, CPO/L, FAAOP

 How do we, as clinicians, provide optimal O&P care for our patients in an ever-changing landscape of payment issues, government oversight, and regulatory policies? This has become an oft-asked question, as year by year more intrusive regulations, statutes, and documentation requirements steal precious patient contact time away from practitioners. Clinical care providers, for the most part, enter their professions with a humanitarian purpose in mind. Few enjoy being relegated to transcriptionists who spend a large part of their time documenting events rather than treating patients. Many of us in the O&P profession are no exception.

As would be anticipated, newly certified O&P practitioners have as their singular focus the goal of returning patients to the highest level of function possible. During their early years of practice however, those clinicians quickly begin to comprehend the myriad of other issues that must be dealt with that stand in the way of providing optimal care. Not the least of these is the challenge of being fairly reimbursed for the professional services provided to our patients. During my 35-year O&P career, healthcare reimbursement requirements have changed dramatically.

In 1985 when I entered the profession, the requirements were relatively simple. Physicians would refer a patient to an O&P provider who would then perform an evaluation to determine the type and design of the device to be provided. In those days, the physician's handwritten prescription was accepted as sufficient documentation for reimbursement by essentially all insurance payers, as well as Medicare and other state and federal agencies. Physicians would write broad-based prescriptions to allow the practitioner to decide what specific orthosis or prosthesis would be most suitable for each patient being treated. Decisions about the use of a rigid ankle versus a hinged ankle on an orthosis were left to the professional discretion of the orthotist. Similarly, the prosthetist would determine the design of the prosthetic socket along with which prosthetic foot would be most suitable for a particular patient to meet his or her goals. Once these device-related decisions were made, verification of the payment source for coverage would be done. Then, the device would be fabricated and delivered to the patient.

Fast forward to today. Patients are still referred to an O&P provider with a handwritten order, known as a dispensing prescription, by a physician, physician assistant, nurse practitioner, or clinical nurse specialist. Generally, handwritten prescriptions remain generic in content as referring physicians continue to depend upon the expertise of the orthotist or prosthetist to assess patient needs and recommend the most appropriate device. ­Recommendations are discussed with the patient so that there is an understanding of why a specific device will best meet the agreed-upon goals established by the patient and the practitioner.

Now, however, code-specific prescriptions with descriptions of each component to be included in that device must be formulated and sent to the physician for signature. The billing codes of those prescriptions describe the specific design and components to be incorporated into the device and must be accompanied by supporting ICD-10 or diagnostic codes. The evaluation, signed prescription, chosen codes (billing and ICD-10), and any other relevant materials are then verified for insurance coverage. Coverages are based upon each individual's policy criteria regarding whether a device is covered, whether it requires prior authorization, or whether it falls within the policy limits at all. In the case where prior authorization is required, supporting documentation must be forwarded along with the authorization request for review by the individual's third-party payer. Once appropriate policy verification is complete, the custom prosthesis or orthosis is fabricated, fitted, and delivered to the patient.

Following the delivery, an invoice for the service is then submitted to the payer. The payer then reviews all documentation provided with the invoice to determine if the documentation is sufficient to justify payment. If the documentation is deemed insufficient, the claim may go into an audit process, which in some cases could take months, or even years, to resolve.

With governmental programs such as Medicare, the dollars being taken in to cover the benefit are not keeping pace with the expenses going out. Multiple sources indicate that the Medicare fund does not have sufficient resources to cover expenditures over the long term. In response, governmental policy changes are being made to "protect" the program by doing such things as changing coverage criteria to reduce costs. As a result, the quantity and quality of care being delivered to Medicare recipients may be compromised by lack of access or coverage restrictions. Medicare beneficiaries have the reasonable expectation that their earned benefit will adequately and appropriately cover their healthcare needs when they turn 65. With regard to O&P care, their anticipation is not that it will only cover the least expensive orthotic or prosthetic device or a device that is simply sent to them in the mail—leaving them to figure out how to use it.

As clinicians, we must be cognizant of all proposed changes to Medicare or by other governmental or private payers that might adversely affect our profession and the well-being of our patients. We can work with the patient population to maintain and improve coverages for those who require O&P devices. Equally important is the assurance that these services are only provided to patients by appropriately trained and credentialed individuals.

So how should we as clinicians, and individuals who require our services, approach this? Clinicians should review the monthly and quarterly updates posted by insurance companies for policy/coverage changes. Insurance companies do not provide notice of policy changes to coverage criteria to individual policyholders.Policy modifications tend to restrict higher cost, technology-based components by raising the bar for eligibility for those components. An astute understanding of the policies and rules of individual payers enhances the provider's ability to write successful letters of medical necessity.

Clinicians and administrative staff should review each Local Coverage Determination (LCD) issued by Medicare for coverage parameters for different types of devices. The LCDs provide clinicians with documentation requirements needed to support the usage of different components.

As a profession, we must know the requirements for functional levels and the documentation required to receive payment for components. It is in the best interests of providers and patients to be aware of the fine details for all devices. Device coding is being bundled for some orthoses or exclusions from coverage for certain types of components when paired with specific diagnostic codes. Other required information includes the O&P practitioner's and physician's notes that give corroborative support about the level of technology deemed appropriate for an individual's needs. 

Patients need to be aware of the coverage criteria of the insurance plans they have purchased. Many insurance plans have O&P exclusions or caps written into the fine print of the contract. Most O& P practices can help recommend an insurance broker that can review policies with the patient so that the patients are aware of exclusions contained in the language of the written policy. This also may require a practice to discuss an advanced beneficiary notice with the patient. That notice discloses that the item is not covered by the insurance and explains that in signing the agreement the patient agrees to receive and pay for the device.

Clinicians should not assume that the referring physician has appropriate supporting documentation in the patient's visit notes. Medical records should be requested and reviewed to deem whether further support is needed prior to provision of the device. We should not be afraid to ask physicians to amend notes to provide better support for the prescribed orthosis or prosthesis. This will eliminate issues with documentation requests during the authorization process or during an audit. If a referral source is not comfortable with amending the medical record, he or she will often see the patient again to review and provide appropriate supporting documentation.

It is important for clinicians and facilities to provide realistic expectations for delivery of devices. Technologically advanced components can require authorization processes that can take months to gain. They may also require further appointments such as a team evaluation for review of the patient with a physician at a rehab setting (such as a PM&R doctor specializing in rehabilitation, PT/OT, and the orthotist/prosthetist). This will ensure that the documentation will meet the requisite needs for coverage.

Orthotists and prosthetists in states with licensure need to monitor the existing licensure laws. It is also important to have someone, a lobbyist or an individual, monitor allied healthcare providers for expansions in their scopes of practice that may create issues with existing O&P licensure. There have been changes to licensure laws under the guise of not stifling innovation of enterprising individuals. The lawmakers' misconception in these instances is that licensure laws are not created to box out competition or to protect an industry, but for the protection of the individuals who receive care from orthotists and prosthetists by creating standards of care and minimum levels of education to be allowed to manage, evaluate, and create devices for and the fitting of patients. In today's healthcare climate, it is important that the stakeholders in O&P (companies, owners, clinicians, and patients) are all involved with influencing healthcare policy and changes to policy. The expectation should not be that someone else will take care of things or that the changes won't impact you. The reality is that O& P makes up less than one percent of the dollars spent in healthcare. If the collective stakeholders don't care enough to fight for appropriate reimbursement and coverage of orthotics and prosthetics, who will?


Kevin Hines, CPO/L, FAAOP, is the clinical manager at Arise Orthotics &Prosthetics, Spring Lake Park, Minnesota. He is a member of the American Academy of Orthotists and Prosthetists (the Academy) Lower Limb Orthotics Society.

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