

Christi Grimm, inspector general for the US Department of Health and Human Services (HHS), published a report in late May titled “Medicare Remains Vulnerable to Fraud, Waste, and Abuse Related to Off-the-Shelf Orthotic Orthoses, Which May Result in Improper Payments and Impact the Health of Enrollees.”1 The following is a summary of the report and an analysis of how this report might be used to the advantage of the O&P profession.
In calendar years (CY) 2014 and 2015, the Centers for Medicare & Medicaid Services (CMS) updated the procedure codes for off-the-shelf (OTS) orthotic braces. The updated procedure codes for OTS orthoses were reimbursed at the same amount as the codes for custom-fitted orthoses. However, suppliers that billed for OTS orthoses were not subject to the same requirements regarding licensing, facilities, and shipping. According to a report published in 2018 by the Medicare Payment Advisory Commission (MEDPAC), following this coding update “suppliers had an incentive to bill for OTS orthoses because the payments for these orthoses were the same as for custom-fitted orthoses, but were not subject to additional quality standards.”1
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