AOPA HEADLINES time that the bar for claim documentation has been raised, the quality of submitted claims and supporting documentation has suffered. Thus, Medicare has increased its success rates in recouping payments. “With claim error rates regularly above 70 percent, auditors and claim reviewers have no reason not to expand into the lower-activity claims. We may see more and more activity move into the final level of Medicare appeals: the Administrative Law Judge (ALJ). Many of the prosthetic claims denied in late 2011 and 2012 are just now finding their way to the judges for a final hearing. This trend will likely continue, even though the anecdotal evidence suggested an extraordinarily high prosthetic appeal win rate of greater than 80 percent. Preparing your claims to be appealed all the way to the ALJ level takes patience and perseverance, but this is a necessary persistence to stay in business.” AOPA recently learned CMS has been telling members that taking a claims appeal all the way to the ALJ may take as long as 28 months—an insufferable delay with dramatic consequences for cash flow at both the patient-care and supplier levels. While AOPA’s lawsuit against CMS may provide some relief from the past misdirected and overzealous audits, the future certainly holds serious and continuing challenges that will require O&P providers to adapt in order to survive. And it all comes down to proper documentation in this new world of O&P care—a reality that was underscored at the AOPA World Congress in Orlando in September, where two of the programs devoted to Recovery Audit Contractor (RAC) audits and documentation attracted standingroom-only audiences. AOPA’s phone rings off the hook year-round with questions about RAC audit issues. It was clear at the World Congress that there was concern on the part of practitioners and owners that a new learning curve was needed and that there may indeed be a new normal.
Joe McTernan, director of coding and reimbursement services for AOPA, speaks at the O&P World Congress in September.
A Sort-Of Silver Lining If there can be a silver lining in this situation, AOPA’s October letter to members may have captured it: “Going forward, ‘caution’ is the watchword. The more we push, the more likely we will have a wholesale revision of the present processes. The present state is the ‘new normal’ of claims validation and cannot just go away. It is also performing a very important function of editing out the unqualified prosthetic suppliers, who may presently be in the system. The qualified supplier with good document controls will survive the transient pain of this initial process into the ‘new normal,’ which will continue to serve as a barrier to entry for the unqualified.” The letter closed with this observation and warning, “Beware that requests for a prior approval process or CMS-mandated forms would be a huge step backwards. Most importantly, these proposals would immediately demote us from clinical professionals to Durable Medical Equipment vendors in the eyes of all payers.” There are two other important actions you can take in this effort to survive. First, enlist the support of your senator and representative for The Medicare O&P Improvement Act (HR 3112). When enacted into law, it will help weed out unqualified providers and help curb fraud and abuse, saving $250,000,000 over five years. Every member of the O&P
community should contact his or her senator and representative, urge their support of this bipartisan bill introduced by Rep. Glenn Thompson (R-Pennsylvania) and Rep. Mike Thompson (D-California), and ask them to join the list of co-sponsors, who include (as of Oct. 31, 2013): Representatives Tammy Duckworth (D-Illinois), Tim Griffin (R-Arkansas), Brett Guthrie (R-Kentucky), Peter King (R-New York), Peter Roskam (R-Illinois), Tom Latham (R-Iowa), C.A. Dutch Ruppersberger (D-Maryland), and Aaron Schock (R-Illinois). Second, we must be a united O&P community, and you can help make that happen by ensuring that every O&P provider in your community is an AOPA member. This struggle is the biggest ever faced by the O&P industry. AOPA and its members alone are funding this very expensive lawsuit as well as pursuing multiple other efforts every day to help bring order out of this chaos. This is a time when we must unite. AOPA has put its own financial future on the line. Please note that the relief sought in the lawsuit is only on behalf of AOPA members. We ask that you urge any suppliers or patient-care companies you know are not members to join. Ask them to visit the AOPA home page, www.AOPAnet.org, and click on the “JOIN AOPA NOW” link in the middle of the page. We need everyone in O&P to join AOPA and help us all fight this battle together. a
DECEMBER 2013 O&P Almanac
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