Busy August Turns to Active Fall for O&P Threats and Opportunities
Two major developments occurred in August that impact Medicare orthotic and
prosthetic services. The first involves CMS’s decision not to include
off-the-shelf orthotics in Round Two of the DMEPOS competitive bidding
program. CMS had been contemplating for several months the inclusion of
off-the-shelf orthotics and there were indications that CMS intended to
interpret the term “off-the-shelf orthotics” very broadly. NAAOP, in concert
with other major O&P organizations, met with CMS on several occasions
throughout the summer to advocate for a total exemption of all orthotics and
prosthetics from Round Two of the program. In the alternative, if CMS
intended to press forward with inclusion of off-the-shelf orthotics, we
advocated that CMS should only do so in a manner that would not compromise
patient care.
In mid-August, CMS announced that it would focus on other, more
commodity-based, durable medical equipment for purposes of expansion of
competitive bidding to 91 additional cities across the country over the next
several years. This is a very positive development and indicates CMS’s
recognition that the provision of O&P care is separate and distinct from
durable medical equipment and is far more complex than DME to competitively
bid without risking quality care. However, CMS’s decision on off-the-shelf
orthotics does not mean this issue is laid to rest. There may be future
opportunities for CMS to pursue competitive bidding of off-the-shelf
orthotics and that means the O&P profession must be vigilant on this issue.
In fact, there are other reasonable and appropriate regulations that CMS
could pursue that would be far more appropriate for O&P care. The O&P
Alliance organizations, including NAAOP, have been working for several years
to link the right to receive Medicare payment with the complexity of O&P
care and provider and supplier qualifications to provide those levels of
care. For instance, as part of this approach, CMS should fully recognize
state O&P licensure laws by prohibiting Medicare payment for unlicensed
practitioners in O&P licensure states.
The need for this type of regulation was recently highlighted by the
issuance of an HHS Office of Inspector General (OIG) report entitled
“Questionable Billings from Suppliers of Lower Limb Prosthetics”
(OEI-02-10-00170). In this report, an OIG audit uncovered significant
anomalies with respect to lower limb prosthetic Medicare claims and offered
a series of recommendations to CMS to improve program integrity. One of
these recommendations-which CMS is considering implementing-would require a
face-to-face physician office visit associated with any claim for a lower
limb prosthesis. Unfortunately, a face-to-face physician visit is a
DME-based solution that has been implemented on certain wheelchair
prescriptions as well. NAAOP and the O&P Alliance organizations have been
advocating for a more O&P-targeted approach.
The major failing of the OIG report is that they did not analyze who
supplied the lower limb prostheses analyzed in the report and whether these
suppliers were qualified to provide quality prosthetic care. NAAOP, working
through the O&P Alliance, recently responded on this point to the OIG and
CMS, and again made the case for O&P-specific solutions to O&P challenges.
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