The American Orthotic & Prosthetic Association (AOPA) has released a report it commissioned from Dobson DaVanzo & Associates, Vienna, Virginia, to determine the extent to which Medicare is reimbursing noncertified O&P providers in states that have passed licensure laws for certain O&P services. The results indicate that despite laws passed by Congress in 2000 and 2005 and a 2009 60 Minutes exposé, the Centers for Medicare & Medicaid Services (CMS) has not made any significant change to eliminate payments to unlicensed O&P providers for services provided to Medicare beneficiaries. Further, the proportion of Medicare payments to noncertified O&P providers in licensure states has risen.
For the study, Dobson DaVanzo analyzed Medicare claims data from 2007-2011, which was then compared to prior claims analyses data conducted on behalf of AOPA from 2001-2006. The Dobson DaVanzo report shows that between 2007-2011, of the 3,624,000 total O&P services that CMS allowed, 67.7 percent was billed by personnel other than certified O&P providers. Orthotic base codes were billed by certified O&P personnel for 31.6 percent of allowed charges. (Of the 3,574,020 orthotic base codes, about 12 percent were for off-the-shelf orthotics.) Prosthetic base codes were billed by certified O&P personnel for 84.1 percent of all allowed charges.
An addendum to the report states that a central premise of the analysis is the relationship between an O&P provider being licensed and being certified: “Since the O&P licensing requirements in most states track very closely to the typical certification requirements of training and education, a person who is not certified will almost never meet eligibility for licensure. It is possible to be certified and not licensed, but it is virtually impossible to be licensed and not certified.”
“Taxpayers are seeing billions of dollars go to unlicensed providers in direct violation of what Congress has mandated,” said Thomas F. Kirk, PhD, AOPA president.
The report concludes that if CMS would adhere to the law, “shifting payments to only certified O&P providers could result in better care for beneficiaries and lower Medicare payments.”