Medicare Bills Pass: Impact on O&P

The Senate and House of Representatives each passed Medicare and prescription drug bills June 27 which include provisions impacting O&P.

A conference committee, expected to be appointed shortly, will try to reconcile the two bills before the August Congressional recess, due to intense pressure from the Bush administration and interest groups, according to an online statement from the National Association for the Advancement of Orthotics & Prosthetics (NAAOP).

Although the most controversial issues will likely center around the restructuring of the Medicare program itself, several provisions of the bills affect O&P, Peter Thomas, NAAOP general counsel, pointed out.

The physical therapy direct access amendment proposed by Sen. Blanche Lincoln (D-AR) was combined with several other amendments and passed the Senate by voice vote. "This provision will now be the subject of intense lobbying as the conference committee meets to reconcile the Senate and House bills," Thomas said.

Physical Therapist Direct Access The amendment would create a three-year, five-state demonstration project in which physical therapists would be able to see Medicare patients without a physician prescription. "The amendment as introduced would also define 'qualified physical therapist' in a way that would likely impact the ability of state-licensed physical therapists to provide O&P services, potentially superseding the Negotiated Rulemaking Committee, which is in the final states of its work," Thomas explained.

"The language of the final amendment, however, is not yet known," Thomas continued, adding, "The O&P organizations will likely work together on this issue to appeal to the grassroots O&P field to communicate strong opposition to the amendment to Congress during the month of July."

O&P Fee Freeze One area seen as a victory for O&P is in the area of a proposed O&P fee schedule freeze. Prosthetics, prosthetic devices, and custom-fabricated orthotics would be updated for each of the next ten years under the current fee schedule according to the consumer price index. "Considering&that just four weeks ago during the tax bill debate, the full Senate voted 86-13 to freeze the entire O&P fee schedule for a ten-year period, the result in the Senate Medicare bill should be considered a tremendous victory," Thomas said. "In the Senate bill and even in the House bill, the O&P field has clearly been successful in convincing policymakers that prosthetics and a large portion of orthotics are decidedly NOT like DME and indeed, should be treated separately."

Although clarity as to what is actually included in the Senate bill will not occur until the week of June 30, the legislation most likely includes a seven-year fee schedule freeze for DME, supplies, and some orthotics, Thomas noted. "The provision specifically applies to orthotics devices that are 'non-custom fabricated.' It is not known at this point how broad this term applies on an L-Code by L-Code basis."

Competitive Bidding The House bill contains a provision in the Medicare bill that would require the Health & Human Services (HHS) Secretary to establish and implement nationwide competitive bidding programs for durable medical equipment, "off-the-shelf orthotics," and medical supplies, the NAAOP statement continued. "'Off-the-shelf orthotics' are defined as covered orthotics which 'require minimal self-adjustment for appropriate use and do not require expertise in trimming, bending, molding, assembling, or customizing to fit the patient.' A contract for items and services could only be granted if the provider meets quality and financial standards, the amounts paid for the items and services are less than the fee schedule amounts, and the beneficiary has a choice of multiple providers," NAAOP noted.

"The Secretary would be permitted to exempt areas that were not competitive due to low population density (i.e., rural and non-competitive urban areas). In a major addition to this year's competitive bidding proposal, the Secretary would be permitted to use so-called 'inherent reasonableness' authority to impose fee schedule reimbursement reductions (similar to those achieved through competitive bidding) on non-competitive areas," Thomas continued. "This provision is troublesome because competitive bidding prices could be extended nationwide in non-competitive areas, even through lower reimbursement levels in these areas may cause access problems."

For more information, contact the National Association for the Advancement of Orthotics & Prosthetics: naaop@oandp.com and the American Orthotic & Prosthetic Association: aopa@aopanet.com .

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