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The Magazine for the Orthotics & Prosthetics Profession

J U LY 2019

What To Do Before the Bid Window Closes P.18

Best Practices for Treating Patients in Rural Areas P.32

Preview Clinical and Business Education Sessions Planned for San Diego P.38

Do’s and Don’ts for Device Delivery

Filling the









PP.18 & 44

This Just In: How Proposed Legislation Will Impact O&P Patients P.22



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J U LY 2019 | VOL. 68, NO. 7



24 | Filling the Data Gap Growing numbers of O&P clinicians are seeking to capture patient information and outcome measures data as the healthcare industry recognizes the importance of embracing “big data.” Some O&P practices have instituted their own processes to collect and analyze facility-wide data to inform clinical decision making and prepare for future value-based reimbursement models. But more O&P companies will need to adopt a data collection mindset in anticipation of the coming Limb Loss and Preservation Registry, which is being developed by the Mayo Clinic and funded by the National Institutes of Health and the U.S. Department of Defense. By Christine Umbrell

P. 22

22 | This Just In

Improving Patient Care Via Legislation The entire O&P community stands to benefit from the provisions included in two important pieces of legislation: the Medicare O&P Patient-Centered Care Act, designed to ensure that Medicare beneficiaries receive appropriate, safe, and effective O&P care, and the Wounded Warrior Workforce Enhancement Act, which would authorize funds to expand O&P master’s programs.

P. 32

32 | Going Rural Clinicians who treat individuals in under-served parts of the United States are challenged by patients who may have reduced access to general healthcare and who must travel long distances to visit O&P facilities. Experienced clinicians share unique patient solutions and strategies for optimal patient care in rural areas. By Meghan Holohan

38 | Surfing the Waves of Knowledge Get a sneak peek at the educational sessions planned for the 2019 AOPA National Assembly in San Diego. From clinical presentations designed with a multidisciplinary approach, to business sessions featuring easy-to-implement best practices, to technical education and pedorthic sessions, the curriculum has something for everyone. By Deborah Conn



P. 38

“There are things in life that you can't choose. But I can always choose to be free.” Shiori Harms Law student & passionate dancer


© Össur, 06.2019


DEPARTMENTS Views From AOPA Leadership......... 6

Special events at the 2019 National Assembly

AOPA Contacts.......................................... 8 How to reach staff

Numbers...................................................... 10 At-a-glance statistics and data


Research, updates, and industry news

People & Places........................................16


Transitions in the profession

COLUMNS Reimbursement Page.......................... 18

The Beginning of Bidding Prepping for rule changes regarding off-the-shelf orthoses

CE Opportunity to earn up to two CE credits by taking the online quiz.


Compliance Corner.............................. 44

Proving Delivery


Do’s and don’ts for delivering O&P devices CE Opportunity to earn up to two CE credits by taking the online quiz.



Member Spotlight........................ 53 n n

AOPA News...............................................56


AOPA meetings, announcements, member benefits, and more

Long Island O&P/North Shore Orthotics-Prosthetics

AOPA New Members........................... 57 P.55


Ad Index...................................................... 57 Careers.........................................................58 Professional opportunities

Marketplace............................................. 60 Calendar..................................................... 62 Upcoming meetings and events

Michael Wininger, PhD............................................... 48 Meet a University of Hartford professor with expertise in force myography who “multitasks” in clinical practice, academic research, and career training.



Ask AOPA.................................................. 64 Replacement rules

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Education, Exhibits, and Special Guests



we hope you are thinking ahead to September when AOPA will host its 2019 National Assembly in San Diego. AOPA staff and industry professionals serving on the 2019 AOPA National Assembly Planning Committee, in partnership with the California Orthotics and Prosthetics Association, have worked diligently to organize a diverse event. Spanning six days with more than 40 CE credits offered, the AOPA National Assembly will feature the O&P industry’s largest U.S. exhibit hall and entertaining networking activities. This year’s theme, “Driving the Waves of Change,” reflects the need for O&P providers and suppliers to actively engage in shaping the future delivery of orthotic and prosthetic care. While we hope gentle breezes will fill our sails, wise sailors continuously look to the horizon and stay prepared for unpredictable circumstances. When planning the National Assembly, staff and volunteers define the general framework and daily schedule for the week. There are workgroups for business, clinical, pedorthic, and technical education, and a workgroup focused on exhibits and marketing. Their collective effort is highlighted in the Preliminary Program, which can be viewed on AOPA’s website. The “Schedule at a Glance,” found on pages 6-7 of the program, provides a great summary of events, which span from 10 a.m. on Tuesday, September 24, through midday on Sunday, September 29. Selecting the keynote speakers is always an inspiring and challenging process. This year’s special guests include the former commanding officer for the medical treatment facility on the Military Hospital ship USNS Comfort. Capt. Lanny Boswell, retired, who also chaired the Congressionally Directed Medical Research Programs O&P Outcomes Programmatic Panel, will share his experiences and perspectives during the opening session Wednesday afternoon. The closing general session, Saturday morning, will feature Paralympic Gold medal winner Jeremy Campbell. An amputee since the age of 1, he will share his inspirational journey and motivate attendees to treat obstacles as opportunities. When planning your travels, be sure to arrive in time to attend AOPA’s Night at the Ballpark on Tuesday evening, with an opening pitch at 7:10 p.m. The San Diego Padres are playing the Los Angeles Dodgers, and Petco Park is right across the street from the convention center. Visit https://groupmatics.events/event/AOPA2019 for discounted tickets. As is customary, there will be manufacturer-sponsored workshops on Wednesday and educational courses throughout the day on Thursday, Friday, and Saturday. Course descriptions and speaker profiles are included in the Preliminary Program, and highlights of the educational sessions are featured in the article “Surfing the Waves of Knowledge” on page 38 of this issue of O&P Almanac. Attendees also are encouraged to participate in the O&P Political Action Committee appreciation reception (all donors are invited) on Thursday evening, which will be followed by a benefit concert for the Veterans Stride Foundation featuring country rocker Eddie Montgomery. Rick Riley is co-chair of the 2019 National Assembly Planning Committee and a member of AOPA’s Board of Directors.



Specialists in delivering superior treatments and outcomes to patients with limb loss and limb impairment.

Board of Directors OFFICERS President Jim Weber, MBA Prosthetic & Orthotic Care Inc., St. Louis, MO President-Elect Jeffrey Lutz, CPO Hanger Clinic, Lafayette, LA Vice President Traci Dralle, CFM Fillauer Companies, Chattanooga, TN Immediate Past President Michael Oros, CPO, LPO, FAAOP Scheck and Siress O&P Inc., Oakbrook Terrace, IL Treasurer Jeffrey M. Brandt, CPO Ability Prosthetics & Orthotics Inc., Exton, PA Executive Director/Secretary Eve Lee, MBA, CAE AOPA, Alexandria, VA DIRECTORS David A. Boone, BSPO, MPH, PhD Orthocare Innovations LLC, Edmonds, WA J. Douglas Call, CP Virginia Prosthetics & Orthotics Inc., Roanoke, VA Mitchell Dobson, CPO, FAAOP Hanger Clinic, Grain Valley, MO Elizabeth Ginzel, MHA, CPO NovaCare P&O, Fort Worth, TX Kimberly Hanson, CPRH Ottobock, Austin, TX Teri Kuffel, JD Arise Orthotics & Prosthetics Inc., Spring Lake Park, MN Rick Riley Thuasne USA, Bakersfield, CA Linda M. Wise WillowWood, Mount Sterling, OH



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American Orthotic & Prosthetic Association (AOPA) 330 John Carlyle St., Ste. 200, Alexandria, VA 22314 AOPA Main Number: 571/431-0876 AOPA Fax: 571/431-0899 www.AOPAnet.org

Publisher Eve Lee, MBA, CAE Editorial Management Content Communicators LLC Advertising Sales RH Media LLC

Our Mission Statement Through advocacy, research, and education, AOPA improves patient access to quality orthotic and prosthetic care.

Our Core Objectives AOPA has three core objectives—Protect, Promote, and Provide. These core objectives establish the foundation of the strategic business plan. AOPA encourages members to participate with our efforts to ensure these objectives are met.



Eve Lee, MBA, CAE, executive director, 571/431-0807, elee@AOPAnet.org

Joe McTernan, director of coding and reimbursement services, education, and programming, 571/431-0811, jmcternan@AOPAnet.org

Tina Carlson, CMP, chief operating officer, 571/431-0808, tcarlson@AOPAnet.org GOVERNMENT AFFAIRS Justin Beland, director of government affairs, 571/ 431-0814, jbeland@AOPAnet.org COMMUNICATIONS, MEMBERSHIP & MEETINGS

Reimbursement/Coding: 571/431-0833, www.LCodeSearch.com


Joy Burwell, director of communications and marketing, 571/431-0817, jburwell@AOPAnet.org

Ashlie White, MA, director of strategic alliances, 571/431-0812, awhite@AOPAnet.org

Betty Leppin, manager of member services and operations, 571/431-0810, bleppin@AOPAnet.org


Kelly O’Neill, CEM, manager of membership and meetings, 571/431-0852, kelly.oneill@AOPAnet.org Ryan Gleeson, CMP, assistant manager of meetings, 571/431-0836, rgleeson@AOPAnet.org Yelena Mazur, communications specialist, 571/431-0835, ymazur@AOPAnet.org Kristen Bean, membership and meetings coordinator, 571/431-0876, kbean@AOPAnet.org AOPA Bookstore: 571/431-0876 8

Devon Bernard, assistant director of coding and reimbursement services, education, and programming, 571/431-0854, dbernard@AOPAnet.org


Eve Lee, MBA, CAE, executive director/publisher, 571/431-0807, elee@AOPAnet.org

Design & Production Marinoff Design LLC Printing Sheridan SUBSCRIBE O&P Almanac (ISSN: 1061-4621) is published monthly by the American Orthotic & Prosthetic Association, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314. To subscribe, contact 571/431-0876, fax 571/431-0899, or email ymazur@AOPAnet.org. Yearly subscription rates: $59 domestic, $99 foreign. All foreign subscriptions must be prepaid in U.S. currency, and payment should come from a U.S. affiliate bank. A $35 processing fee must be added for non-affiliate bank checks. O&P Almanac does not issue refunds. Periodical postage paid at Alexandria, VA, and additional mailing offices. ADDRESS CHANGES POSTMASTER: Send address changes to: O&P Almanac, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314. Copyright © 2019 American Orthotic and Prosthetic Association. All rights reserved. This publication may not be copied in part or in whole without written permission from the publisher. The opinions expressed by authors do not necessarily reflect the official views of AOPA, nor does the association necessarily endorse products shown in the O&P Almanac. The O&P Almanac is not responsible for returning any unsolicited materials. All letters, press releases, announcements, and articles submitted to the O&P Almanac may be edited for space and content. The magazine is meant to provide accurate, authoritative information about the subject matter covered. It is provided and disseminated with the understanding that the publisher is not engaged in rendering legal or other professional services. If legal advice and/or expert assistance is required, a competent professional should be consulted.

Josephine Rossi, editor, 703/662-5828, jrossi@contentcommunicators.com Catherine Marinoff, art director, 786/252-1667, catherine@marinoffdesign.com Bob Heiman, director of sales, 856/673-4000, bob.rhmedia@comcast.net Christine Umbrell, editorial/production associate and contributing writer, 703/6625828, cumbrell@contentcommunicators.com

Advertise With Us! Reach out to AOPA’s membership and more than 11,400 subscribers. Engage the profession today. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net. Visit bit.ly/almanac19 for advertising options!

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Healthcare in Rural Areas Some rural Americans—particularly those with disabilities—struggle to get needed healthcare


1,860 106 673

Approximate number of rural hospitals in the United States today



Percentage with disabilities who report a problem with quality of healthcare received

Percentage with disabilities who report having problems paying medical or dental bills

Percentage with disabilities who report a problem paying off an unexpected expense of $1,000



Most convenient way to get diagnosis or treatment


Couldn’t see a regular doctor in person




Too hard to travel to doctor/hospital

Reasons Why Rural Americans Did Not Get Needed Healthcare* Among those who reported having experienced healthcare access problems Could not afford healthcare


Healthcare location was too far or difficult to get to


Could not get an appointment during hours needed


Could not find a doctor who would take their health insurance


“About three in 10 rural Americans (29 percent) say they have a disability that keeps them from participating fully in work, school, housework, or other activities. Rural Americans with disabilities say they face significant challenges with financial security, healthcare, and isolation in their communities.”


*Respondents could choose more than one response.





Number of hospitals that have closed in rural America since 2010

Number of rural hospitals that are at risk of closure



—“Life in Rural America: Part II”

SOURCES: “Life in Rural America—Part II,” NPR/Robert Wood Johnson Foundation/Harvard T.H. Chan School of Public Health; “Rural Relevance—Vulnerability to Value: A Hospital Strength Index Study”


O&P clinicians who serve rural areas are faced with many challenges, including treating patients with reduced access to healthcare. While 87 percent of rural Americans have health insurance of some sort, more than one quarter (26 percent) reported not having been able to get healthcare when they needed it at some point in recent years. This disparity was one of several key findings in “Life in Rural America: Part II,” published in May 2019 by NPR/Robert Wood Johnson Foundation/Harvard T.H. Chan School of Public Health. The report features the findings of a survey conducted among rural Americans, where “rural” was defined as areas that are not part of a Metropolitan Statistical Area.



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Researchers Debut Open-Source Artificially Intelligent Prosthetic Leg Scientists at the University of Michigan (UM) and Shirley Ryan AbilityLab have developed an open-source “smart” prosthetic leg that is available to the scientific community. Led by Elliott Rouse, PhD, core faculty at UM’s Robotics Institute, and Levi Hargrove, PhD, director of the Neural Engineering for Prosthetics and Orthotics Laboratory at the Shirley Ryan AbilityLab, the research team debuted the technology during Amazon’s Re:MARS conference in Las Vegas in June. The prototype features a modular design that can act as a knee, ankle, or both. The research team adapted and incorporated advanced motor technology popular in the drone industry. The device’s artificial intelligence-based control system can adapt the actions of the bionic leg to allow the user to switch activities—for example, to switch from walking on a flat surface to navigating stairs. This control is enabled using muscle contraction signals and sensor data from within the robotic prosthesis to anticipate the user’s next move and respond appropriately. “While the designs and code are free, the leg is still a high-end, state-of-the-art machine,” Hargrove said. “It’s a unique plug-and-play system that allows scientists to avoid research and development costs in the millions of dollars and



immediately begin testing on prosthetics for the knee and ankle. It effectively lowers the barriers to entry for researchers.” The goal of the project is to unite researchers in prosthetic hardware design, prosthetic control, and amputee biomechanics to work together in advancing the design. Using this approach will “lower the barrier for conducting research as investigators will no longer be required to invest the prohibitive time and monetary cost of developing their own systems from scratch,” according to the project website. “Our open-source bionic leg will enable investigators to efficiently solve challenges associated with controlling bionic legs across a range of activities in the lab and out in the community,” said Rouse. “In addition, we hope our bionic leg will unite researchers with a common hardware platform and enable new investigators from related fields to develop innovative control strategies.”

Kim Ingraham, ME, PhD, runs tests on an open-source robotic leg with Musil.

PHOTO: Joseph Xu/Michigan Engineering, Communications & Marketing

Elliott Rouse, PhD, runs tests on an open-source robotic leg with Musil.

Dawn Jordan Musil tests an open-source robotic leg designed by Elliott Rouse, PhD, and his research group in May.



MIT Team Develops Sensor-Embedded Glove

MIT researchers have developed a low-cost, sensor-packed glove that captures pressure signals as humans interact with objects. The glove can be used to create high-resolution tactile datasets that robots can leverage to better identify, weigh, and manipulate objects.

PHOTO: Courtesy of MIT researchers

A newly developed scalable tactile glove, or STAG, can capture pressure signals as users interact with objects, according to researchers from the Massachusetts Institute of Technology (MIT) who developed the prototype. These pressure signals can be leveraged to create high-resolution tactile datasets that can help identify, weigh, and manipulate objects. The information captured may one day be used to aid in robotics and prosthetics design. MIT researchers developed the STAG system so that a neural network can process the captured pressure signals to "learn" a dataset of patterns related to specific objects. The system relies on the dataset to classify objects and predict their weights. The tactile sensing system could be used in combination with traditional computer vision and image-based datasets to give robots a more human-like understanding of interacting with objects, according to the research team.

“Humans can identify and handle objects well because we have tactile feedback. As we touch objects, we feel around and realize what they are. Robots don’t have that rich feedback,” explained Subramanian Sundaram, PhD, a former graduate student in MIT’s Computer Science and Artificial Intelligence Laboratory. During one clinical trial, the MIT team compiled a dataset using STAG for 26 common objects, including a soda can, scissors, and a pen. The system predicted the objects’ identities with up to 76 percent accuracy and predicted weights of most objects within 60 grams. Details were published in the May 29 issue of Nature magazine. Prosthetics manufacturers may one day leverage information from the datasets to select optimal spots for placing pressure sensors in prostheses and to help customize prostheses to user tasks and objects, according to the research team.

Amputations Follow Diabetes Diagnoses

“In the United States, every 17 seconds someone is diagnosed with diabetes, and every day 230 Americans with diabetes will suffer an amputation. Throughout the world, it is estimated that every 30 seconds a leg is amputated. And 85 percent of these amputations were the result of a diabetic foot ulcer.”

—Fuloso A. Fakorede, MD, “Increasing Awareness This National Diabetes Month Can Save Limbs and Lives,” American Journal of Managed Care






TMR May Reduce Phantom and Residual Limb Pain

First Clinic Participants Celebrate Limb Loss Awareness Month



intensity, behavior, and interference, comparing data from the study subjects to data collected from 438 major limb amputees who did not undergo TMR. The researchers found that patients who underwent TMR had less phantom limb pain and residual limb pain compared with the untreated amputee control subjects, as measured by best, current, and residual pain scores. Valerio, Dumanan, and their team concluded that pre-emptive surgical intervention of amputated nerves with TMR at the time of limb loss should be strongly considered to reduce phantom limb pain and residual limb pain. Study results were published in the March 2019 issue of Journal of the American College of Surgeons.

Custom-Made AFOs May Be Effective in Fall Prevention for Older Adults

PHOTO:Getty Images

Two First Clinics held in New York in April convened O&P educators and patients to focus on physical activity during Limb Loss Awareness Month. Prosthetic Orthotic Associates hosted a First Things First Clinic at Marist College in Poughkeepsie, New York. Chris Doerger, PT, CP, led the event, which was attended by local therapists, Marist DPT students, practitioners, and local lower-limb amputees. Attendees discussed fall prevention and recovery, and participants learned a reverse chain method for rising from the floor after a fall. Complete Orthopedic Solutions Inc. hosted a First Stride Clinic at its new location in East Meadow, New York. Sheila Clemens, PhD, PT, led the full-day session, which included classroom and lab experience. Instructors offered an introduction to gait training for the lower-limb amputees.

Patients who underwent a targeted muscle reinnervation (TMR) procedure while undergoing limb amputation were found to have reduced limb pain and reduced phantom limb pain postamputation, according to a new study. Researchers, led by plastic surgeons Ian Valerio, MD, MS, MBA, FACS, from Ohio State University, and Gregory A. Dumanan, MD, FACS, from the Northwestern Feinberg School of Medicine, conducted a cohort study between 2012 and 2018, studying 51 patients undergoing major limb amputation with immediate TMR surgery. They used an 11-point Numerical Rating Scale and the Patient-Reported Outcomes Measurement Information System (PROMIS) to study pain

The daily use of bilateral custom-made ankle-foot orthoses (AFOs) and walking shoes, in conjunction with a healthy diet and exercise, has been found to be beneficial for older adults with concerns about or at risk of falling, according to a new study by Bijan Najafi, PhD, and his research team at the Baylor College of Medicine. The researchers conducted a randomized control trial investigating the effectiveness of daily use of a custom-made AFO on balance, fear of falling, and physical activity in the senior population. They developed a protocol involving 44 older adults with fall concerns, with half allocated to an intervention group and the other half to a control group. The intervention group received walking shoes and bilateral custom-made AFOs (Moore Balance Brace); the control group received only walking shoes. Researchers assessed participants’ balance and physical activity at the

baseline and during six-month follow-up visits, using wearable instrumentation and the Fall Efficacy Scale–International assessment tool. While the research team observed no significant differences between the intervention group and control group at the baseline visits, they measured reductions in hip, ankle, and center-of-mass sways among the intervention group six months later. Overall, Najafi and his team identified a 55 percent reduction in center-ofmass sway, a 41 percent reduction in hip sway, and a 71 percent reduction in ankle sway among subjects who followed the suggested protocol of diet, exercise, and doctor visits and wore the AFOs. They concluded that the combination of bilateral custom-made AFOs plus walking shoes is effective in improving balance when compared to walking shoes alone and significantly reduces the fear of falling among older adults. The research was published in a recent issue of Gerontology.



ABC Debuts Combined Practitioner Exam

PHOTOS: Getty Images

The American Board for Certification in Orthotics, Prosthetics, & Pedorthics (ABC) has introduced a combined written examination for practitioner candidates. The combined written exam is designed for graduates of a combined orthotics and prosthetics master’s degree program and can be taken immediately after graduation. The combined exam tests the knowledge the candidates gained from their master’s programs but does not include any clinical experience that they will gain during their O&P residency.

“This change not only gives candidates the opportunity to take the exam while their university knowledge is still fresh,” said ABC Clinical Resources Director Steve Fletcher, CPO, LPO, “but provides educators with measures to evaluate the success of their curriculum.” Registration for the first combined practitioner written exam closed July 1 for the exam offered the week of August 5-10. The combined exam will be given every other month in addition to the single-discipline written practitioner exams. Visit www.abcop.org for details.



UTSW MSOP Students Awarded Grant To Support First Clinics

Students at University of Texas Southwestern (UTSW) Medical Center preparing for OPAF First Clinics this fall were awarded grant funding from the Barr Amputee Assistance Fund. The $3,000 grant will support the First Dance and First Volley Tennis Clinics that UTSW students will host on October 12 on the campus of Southern Methodist University. Alps South, Spinal Technology, and SPS also provided support. “The goal of our event is to build community for adaptive athletes in the Dallas–Fort Worth area by hosting introductory sports events,” said Olivia Sheffer, one of the event organizers.







Nicki Chamberlain-Simon has been awarded the 2019 Dale Yasukawa Scholarship. ChamberlainSimon is expected to graduate from Northwestern University’s master’s program in prosthetics and orthotics in March 2020. She holds a bachelor of Nicki Chamberlain- science engineering degree from Rice University. Simon She also has clinical research and volunteer experience, both in the United States and in Costa Rica. Chamberlain-Simon will receive a $1,000 scholarship to further her education by attending a national, regional, or local chapter or society meeting. Funds also may be used for educational purposes.

The Dralla Foundation, which supports programs for children and adults with physical challenges, has awarded grants to several organizations for 2019, including Arizona Disabled Sports, Camp Jabberwocky, Camp Rise Above, Catalyst Sports, Gateways Community Services, Jett Foundation, OPA, Paradox Sports, and Shirley Ryan AbilityLab. Some of the events that will be supported through the grants include a 100-mile trek on the Camino de Santiago in Spain; a day of ice skating, ice climbing, skiing, and other activities; and a two-night adventure featuring zip lining, tower climbing, and archery. The Dralla Foundation will begin accepting grant applications for the next grant cycle in December, with a submission deadline of Feb. 1, 2020. The organization was founded by Peter Allard, president of Allard USA, and awards grants each year to select nonprofits that are aligned with its mission.

Fillauer Companies Inc. has named Michael Leach, CPO, as its new clinical research and development specialist. Leach will assist with education, support, and development direction for all Fillauer O&P-related products and services. Michael Leach, Leach has experience as a clinician, educator, CPO and lecturer, with extensive knowledge in both prosthetics and orthotics. He has more than 27 years in clinical practice, as well as 13 years on a clinical service team, and worked in research and development for Ottobock. Amanda Ramos has been promoted to the position of patient-care coordinator at Premier Prosthetics. Ramos, a native and resident of San Antonio, was previously the company’s marketing and social media coordinator. Amanda Ramos Ramos will serve as a liaison between patients and the healthcare system, ensuring that patients receive the assistance and continuation of care needed. She also will assist in collecting documentation from referring and primary physicians. Jörg Wahlers has been appointed the new chief financial officer (CFO) at Ottobock and will assume the position on August 8. Wahlers has extensive experience as a CFO and most recently worked at Jack Wolfskin. The hiring of Wahlers will allow Philipp Schulte-Noelle, who has held the roles of both CFO and chief executive officer (CEO) since November 2018, to focus on his role as CEO. Together with Professor Hans Georg Näder, chairman of the Management Board, Schulte-Noelle will continue to place an intensive focus on developing the company’s future growth opportunities, according to a press release.



AOPA Supplier Plus Partners Thank you to our AOPA Supplier Plus Partners for their continued support of the association.


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The Beginning of Bidding





Know the steps leading up to the start of Competitive Bidding 2021

Editor’s Note—Readers of CREDITS Reimbursement Page are eligible to earn two CE credits. After reading this column, simply scan the QR code or use the link on page 21 to take the Reimbursement Page quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.


Clarification to Last Month’s Views From AOPA Leadership




program is now in full swing. This month’s Reimbursement Page breaks down the timeline—examining what each of the key dates mean and what you can do to prepare.

March 7, 2019: CMS Announces Competitive Bidding 2021

As expected, certain off-the-shelf (OTS) knee orthoses and spinal orthoses were included as product categories in Round 2021 of the competitive bidding program—a total of 16 OTS spinal orthosis codes and seven OTS knee orthosis codes. CMS also announced that it would consolidate the competitive bidding areas (CBAs) included in previous rounds and conduct Round 2021 in those same geographic areas, resulting in a total of 130 CBAs across 42 different states and the District of Columbia. If you plan to place a bid during Round 2021, you will be required to meet some eligibility requirements by the closing of the bid window. First, you must be in good standing with the National Supplier Clearinghouse (NSC); you must have an active and valid Medicare supplier number. Your enrollment information must be up to date in the Provider Enrollment, Chain, and Ownership System (PECOS), especially the contact information for your Authorized Officials. This information will be important when you register for the bidding program. Second, you must be accredited by a CMS-approved accrediting

organization for each product category for which you submit a bid. There are no exemptions for this requirement. While it’s true that suppliers of certain orthoses and prostheses are exempt from the current mandatory accreditation for Medicare enrollment, that exemption does not apply to the competitive bidding program. You also must have obtained the required state licenses for the items in the product category you are bidding on. If you are not clear on what licenses you may need, review the NSC licensure database. Next, you must obtain a $50,000 bid surety bond for each CBA where you intend to submit a bid. This bond is separate from the bond needed to secure your Medicare enrollment—and, again, there are no exemptions. Finally, you will need to compile a series of financial documents often referred to as “covered documents.” It may take some time to assemble all

PHOTO: Getty Images

In the June 2019 O&P Almanac, in the Views From AOPA Leadership column, “To Bid, Or Not To Bid?” (page 4), it was stated that if you are not awarded a contract in a competitive bidding area, you will not be allowed to use an Advance Beneficiary Notice (ABN) and provide those competitively bid off-the-shelf braces to Medicare beneficiaries; and the beneficiary must go to a contracted supplier. However, the Competitive Bidding Implementation Contractor (CBIC) has stated that, under the competitive bidding program, “non-contract suppliers are supposed to notify beneficiaries of their options for coverage; if the beneficiary opts to receive the item anyway, [the supplier] should administer the ABN and indicate they are not a contract supplier.” You also should document that you notified the beneficiary of the options and what his or her decision was.



of the covered financial documents, which include the following: • A tax return extract for the most recent year in which you filed a claim (either a calendar year or a fiscal year) • A set of financial statements, including an income statement, a balance sheet, and a statement of cash flows (all of these statements must be for the same 12-month period and match the reporting period of the tax return extract) • A credit report and score/rating for your business from one of the four approved reporting agencies (Dun & Bradstreet, Experian, Equifax, or Standard & Poor’s); the report must be recent—prepared no earlier than 90 days prior to the open of the bid window; so it must be a recent report (if you don’t have a company/business credit report, a personal credit report for the primary business owner may suffice). The Competitive Bidding Implementation Contractor (CBIC) has stated that a majority of the

publicly available accounting software program settings may not generate the properly formatted financial statements. It is recommended that you use a professional accountant to help you prepare your covered documents. The proper formats and the exact information required for each statement can be found in the CBIC’s Round 2021 Request for Bids Manual.

June 10, 2019: Registration Window Opens

The registration window for Connexion and the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Bidding System (DBidS) opened June 10. DBidS is what you will use to complete and submit your bid when the bidding window opens in mid-July. Connexion is the competitive bidding program’s secure document portal and will be your primary resource for information about your bids. In short, you will use Connexion to upload your covered documents and surety bond, view the status of bid submissions,

update any missing documents, and accept or reject any contract offers. Before you can register, you must create a username/ID and password with the CMS Enterprise Portal (https://portal.cms.gov); this involves a simple four-step process: 1. Visit the portal and click on the option for “New User Registration.” 2. Choose the application for which you are looking to register and select “DBidS” or “Connexion,” then review and accept the terms and conditions. 3. Enter your personal information (name, birthdate, etc.) and your personal contact information (home address, email, phone number, etc.). 4. Create a password and answer security questions; review the information and click “Submit.” Remember that any person who will be viewing or entering data in DBidS and Connexion must be individually registered in the CMS Enterprise Portal and have his or her own user ID and password.




If you have already created or have an active ID and password, you don’t need to create a new one—simply verify that your account is still active. Once you have created an account, you may log into the CMS Enterprise Portal to request access to DBidS and Connexion separately to complete your registrations. You will need to select your role, such as Authorized Official/ Back-Up Authorized Official or End User; your selection must be the same for DBidS and Connexion. If you select the role of Authorized Individual or Back-Up Authorized Individual, your contact and personal information must match what you used for registration in the enterprise portal and in PECOS. You also will have to provide your company information, including the Provider Transaction Access Number (PTAN)/ Supplier Number for your primary bidding location. You must use the same PTAN to access DBidS and Connexion. Some common mistakes during the registration process include registering more than one PTAN, providing Authorized Official information that doesn’t match your PECOS registration, and using an incorrect ID or password.

Remember to save this number in a separate location for back-up purposes. Once you have a bidder number, you may begin to upload your documents in Connexion. This can be done any time prior to the close of the bid window. Next, complete Form B, the bidding form. Form B will autopopulate certain fields based on the product categories you selected on Form A. In addition to inputting your bid amount, you will be asked to provide information on the types of items you will provide (manufacturer, model name, model number, etc.) and the total number of units of the lead item(s) you provided to both Medicare and non-Medicare patients in the previous calendar year. Make sure your Authorized Official has signed the certification statements—this includes resigning the statements if your bid forms are updated or changed. When completing Forms A and B, allow yourself enough time to input all of the information; check DBidS to make sure all bids are complete; and avoid making keystroke errors, such as entering $10 when you wanted to enter $100.

close of the bidding window. You will be given 10 days to submit and upload the missing documents in Connexion. Remember that a document is not considered submitted until it has been uploaded in Connexion; documents may not be mailed, faxed, emailed, or hand delivered. Check the “My Upload History” section in Connexion on a regular basis to verify your documents have been uploaded successfully.

July 16, 2019: Bid Window Opens

Aug. 16, 2019: DBidS Registration Closes

You must register with DBidS by August 16 to be able to submit a valid bid. However, Connexion registration and access will remain open.

After the close of the bidding window, the CBIC will conduct a preliminary bid evaluation (PBE), a review separate from the covered document review. During the PBE, all of the uploaded information will be examined to determine if key elements have been met and if the bids remain valid, or if they are disqualified. The PBE will determine if a bid was completed, certified, and approved properly in DBidS. Second, the PBE will determine if all of the required documents (financial, surety bond, etc.) were uploaded in Connexion before the close of the bid window. In addition, the PBE will verify that the bidder’s locations meet all Medicare enrollment and competitive bidding requirements. This would include verifying that your PTAN is active, that you are accredited for your product categories, that you are licensed, and whether your PTAN is a common ownership or common control. (Review the Reimbursement Page article in the May 2019 O&P Almanac for details on common ownership/control).

The original bid window open date was set for June 16, 2019, but CMS announced a one-month extension to allow potential bidders more time to compile all of the necessary documentation. Once the bidding window is open and you have an ID/password and have registered with DBidS and Connexion, you may submit your bids and upload the required documents. First, access DBidS and begin filling out the required forms starting with Form A, the bid application; here, you will provide information about your business/company (name, locations, addresses, contact information, licensure, accreditation, etc.) and identify the CBA(s) and product categories you intend to bid in and on. As you complete the company information section of the application, you will be assigned a bidder number that will automatically be applied to your forms in DBidS. 20


Aug. 19, 2019: Deadline Arrives To Submit Documents for a Covered Document Review

The August 19 deadline is recommended but optional; if it is not met, you will not be disqualified. If you meet the August 19 deadline to upload and submit all of your covered documents (tax return extract, income statement, balance sheet, cash flow statements, and credit report—but not your surety bond or any other required documents), they will be reviewed to determine if any covered documents are missing. Note that this is not a review of whether your documents are acceptable or complete. If a required covered document is missing, you will be notified after the

Sept. 18, 2019: Bid Window Closes

The bidding window will close at 9 p.m. EST on Wednesday, September 18. All required information and bids must be submitted and uploaded to Connexion and DBidS by this date and time. You may not upload revised versions of previously uploaded documents or amend your bids after the close of the bid window; however, you will still have the ability to view the status of your bid through DBidS and Connexion.

Fall 2019: CMS Releases Preliminary Bid Evaluation Notifications


Once the PBE is complete, you will receive a notification in Connexion informing you that your bid is eligible for further review, or informing you if any enrollment requirements could not be verified. If required, the notification will include instructions on how you may verify that you have met the enrollment requirements, and you will have 10 days to demonstrate that you met the requirements. Passing the PBE stage is not a guarantee that you will be awarded a contract, or that your bid cannot still be disqualified for other reasons.

Summer 2020: CMS Announces Single Payment Amounts and Begins the Contracting Process

Approximately one year from now, CMS will announce the single payment amount (SPA) for each product in a product category. These amounts will replace the fee schedule amounts in the CBAs starting in January 2021. During this same time period,

CMS will contact bid winners and begin the contracting process. To review how the SPAs are calculated, see the Reimbursement Page article in the May 2019 O&P Almanac or visit the Competitive Bidding 2021 page on the AOPA website.

Fall 2020: CMS Announces Winning Bidders/Contracts

Next fall, CMS will publicly announce the contract winners in each of the 130 CBAs.

Jan. 1, 2021: Round 2021 Prices Will Be Implemented

The first day of calendar year 2021 is the start date of Round 2021 contracts and prices in the CBAs for the 23 OTS knee and spinal braces included in competitive bidding. If you or your patients reside in a CBA and you were not awarded a contract, you may not provide any of the items in the Round 2021 product categories. In addition, if you are awarded a

contract, you must agree to accept assignment on all 23 OTS braces. The contract period will last two years. These dates are current at the time of publishing, but be advised that CMS may change or update these dates at any time. To stay up-to-date on any changes, check the Competitive Bidding 2021 timeline on the AOPA website. Devon Bernard is AOPA’s assistant director of coding and reimbursement services, education, and programming. Reach him at dbernard@AOPAnet.org. Take advantage of the opportunity to earn two CE credits today! Take the quiz by scanning the QR code or visit bit.ly/OPalmanacQuiz. Earn CE credits accepted by certifying boards:


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This Just In

Improving Patient Care Via Legislation

Two proposed bills would protect patients and preserve access to qualified clinicians




Medicare Orthotics and Prosthetics Patient-Centered Care Act


and partners, AOPA is working diligently on two pieces of legislation that will benefit the field and our members while improving quality of care for patients. The first bill, the Medicare Orthotics and Prosthetics PatientCentered Care Act, will ensure that Medicare beneficiaries receive appropriate, safe, and effective orthotic and prosthetic care, as prescribed by their physician. The bill would achieve three goals. One goal is to restore Congress’s intended meaning of “minimal self-adjustment,” which defines off-the-shelf (OTS) orthoses that may be subject to competitive bidding. Congress intentionally exempted all limb prostheses and most orthoses from competitive bidding because of the clinical nature of custom-fabricated and -fit O&P care. However, Congress authorized the Medicare program to competitively bid limited OTS orthotics, stating that OTS orthoses are those that “require minimal self-adjustment for appropriate use and do not require expertise in

trimming, bending, molding, assembling, or customizing to fit to the individual.” This definition intentionally describes a very small segment of orthotic devices, essentially those found only at retail pharmacies or department stores. However, CMS has used an expanded regulatory definition of minimal self-adjustment, which has resulted in the classification of many orthotic items as OTS when, in fact, the items require a level of professional care to avoid potential harm. This expanded definition invites potential abuse of the orthotic benefit, as OTS braces are not subject to CMS quality standards. Ensuring congressional intent on the definition of OTS will reduce patient risk. Next, the Medicare O&P PatientCentered Care Act would help preserve access to care by exempting CPOs and/or LPOs from having a competitive bidding contract to provide OTS orthoses to their patients while providing O&P patient care, like the exemption already utilized by physicians. This provision would guarantee patients have access to the full range of orthotic care from one orthotic/prosthetic practitioner

This Just In

population—including traumatic brain injury, amputation, and stroke—have become more complex. New technologies and devices are available to treat these conditions and improve the quality of life for veterans and civilians alike, but these innovations require more sophisticated, advanced training on the part of clinicians. O&P LEGISLATION

rather than requiring patients to visit multiple providers in the case where the treating orthotist or prosthetist does not have a competitive bidding contract. Under this provision, certified clinicians would be able to provide OTS orthoses, with reimbursement set at the single payment amount as determined by CMS through the competitive bidding process, as to not cost the Medicare program more than it would otherwise spend. Finally, the new legislation would differentiate O&P care from durable medical equipment (DME), ensuring proper, safe, and effective patient care. Currently, O&P providers are grouped with DME suppliers even though the provision of DME commodities is much different than that of O&P care. O&P treatment can take years—even decades—given ongoing mobility needs of amputees or impaired patients. O&P care requires extensive follow-up, requiring a clinical relationship between patients and their O&P providers. Differentiating O&P from DME would allow CMS to create regulations that consider O&P provider education (which requires a master’s degree), skill sets, and the ability to work directly with a patient on custom fitting and fabricating as needed. AOPA is working with a diverse group of legislators, including Reps. G.T. Thompson (R-Pennsylvania) and Mike Thompson (D-California) in the House of Representatives and Sen. Mark Warner (D-Virginia) and others in the Senate to ensure bipartisan input and support of the bill. AOPA also is working closely with Congress on the recently introduced Wounded Warrior Workforce Enhancement Act, HR 2487 in the House and S 1315 in the Senate, which would authorize $5 million per year for three years to provide limited, one-time competitive grants to qualified universities to create or expand accredited advanced education programs in O&P. Over the past decade, the medical conditions faced by a growing veteran

to retire in the next 10 years, current programs cannot graduate enough workers to maintain the current workforce, much less the number of clinicians needed to care for our aging population and veterans. One solution is to expand the number and size of O&P graduate programs—an initiative supported

Wounded Warrior Workforce Enhancement Act

In 2015, the National Commission on Orthotics and Prosthetics Education commissioned a study of O&P. It found that in 2014 there were 6,675 licensed and/or certified orthotists and prosthetists in the United States and concluded that, by 2025, “overall supply of credentialed O&P providers would need to increase by about 60 percent to meet the growing demand.” Despite this trend, O&P programs are not high profile enough, and do not generate enough revenue, for universities to build out enough master’s programs to meet the need. Currently, there are only 13 schools in the U.S. that offer master’s degrees in O&P, and one of those was scheduled to graduate its last class in June 2019. Combined, the schools will graduate fewer than 250 clinicians. With a significant percentage of our nation’s trained and experienced O&P clinicians eligible

by the Wounded Warrior Workforce Enhancement Act. The result of this limited, cost-effective approach to assist universities in creating or expanding accredited master’s degree programs in O&P will be more effective treatment of patients in the U.S. Department of Veterans Affairs (VA), Medicare, and Medicaid programs; fewer co-morbidities; and a reduction in costs. This legislation would give priority to programs partnering with VA or Department of Defense facilities, including opportunities for clinical training, to ensure that students become familiar with and can respond to the unique needs of service members and veterans with limb loss or limb impairment. For more information and to get involved in supporting these two pieces of legislation, visit www.AOPAvotes.org. O&P ALMANAC | JULY 2019



Filling the

Data Gap O&P professionals wade into the ‘big data’ waters as development begins on a Limb Loss and Preservation Registry





NEED TO KNOW • While the concept of “big data” is fairly new to O&P, several facilities have already instituted their own processes to collect and analyze large amounts of facility-wide data to inform clinical decision making and prepare for future value-based reimbursement models. • Facilities that collect outcome measures data are finding that clinicians are making more informed decisions, patients appreciate being able to track their progress, companies are improving certain areas of practice management, and clinicians can provide detailed supporting documentation to physicians and therapists. • These facility-wide data collection efforts serve as a precursor to an effort in its initial stages to collect O&P-specific data on a national basis, in the form of the Limb Loss and Preservation Registry. The prime contractor leading the registry initiative is



has been around for several years now—but O&P-specific big data is just in its early stages. Recognizing the importance of aggregating patientrelated data, forward-thinking O&P professionals are capturing and storing patient information and selected outcome measures. “The idea is to be not necessarily driven by data, but informed by it,” says Brian Hafner, PhD, a faculty member at the University of Washington and a member of the External Collaborative Panel for the national Limb Loss and Preservation Registry (LLPR). “It’s not trying to replace clinical practice, or replace the experience of the practitioners. It’s trying to complement that

the Mayo Clinic, with funding provided by the National Institutes of Health and the U.S. Department of Defense, and in collaboration with AOPA and the American Academy of Orthotists and Prosthetists. • While having one national repository for O&P patient data will offer many benefits and elevate the profession, there are some questions that will need to be addressed regarding who inputs data, how it is extracted and analyzed, and how it will be secured. • As more O&P professionals recognize the importance of collecting data and contributing to a national data repository, it is important to remember that data is just one contributing factor to improving patient care, and should be used in conjunction with clinical experience and the empathy of being a good practitioner to drive clinical decision making.

by trying to gather data that allows us to make informed decisions.” The capture and use of meaningful big data within the world of O&P is in sight, according to Hafner. He foresees a time when O&P clinicians can look to one repository—the LLPR, which is in the early stages of development. The prime contractor leading the registry initiative is the Mayo Clinic, with funding provided by the National Institutes of Health (NIH) and the U.S. Department of Defense (DoD), and in collaboration with AOPA and the American Academy of Orthotists and Prosthetists (AAOP). Once this registry comes to fruition, it will provide a home for outcome measures data and other data points related to O&P. O&P ALMANAC | JULY 2019



Some O&P facilities have already made headway into the world of big data, by implementing processes and systems to measure outcomes among patients, aggregate that information, and input it into their own facility-wide data collection systems. Companies like Hanger Clinic, Ability Prosthetics & Orthotics, and several smaller facilities are collecting their own data in an organized manner, with the intention of better informing clinicians, improving patient care, and driving scientific studies. These efforts serve as models for other facilities just getting started.

Brian Hafner, PhD

What Is Big Data?

Big data is a field that develops ways to analyze, systematically extract information from, or otherwise deal with datasets that are too large or complex to be dealt with by traditional data-processing software, according to Kenton Kaufman, PhD, PE, who is program director/principal investigator for the LLPR and serves as director of the Motion Analysis Laboratory at the Mayo Clinic. “Most clinical practices are not of the scope to consider the data in their practice to meet the definition of big data. However, by combining their data with that of other practitioners, the resulting dataset can be of sufficient size to provide the insights attributed to big data.” Hafner adds that big data “refers to the complexity, challenges, and new opportunities presented by the combined analysis of data.” The term doesn’t just mean “the little pieces of data that you collect across all of these different systems,” but rather, “what do you do with it, how you manage it, 26


how you use it to inform science and clinical practice.” Outside of O&P, other areas of healthcare provide demonstrations where the ability to collect large amounts of data can inform future practice, explains Shane R. Wurdeman, PhD, CP, FAAOP, director of clinical research, Hanger Clinic Department of Clinical & Scientific Affairs. “This is critically more important in a field such as O&P, which is so small in the spectrum of healthcare issues,” he says. “The result of our size makes large-scale prospective studies challenging. Capturing common data elements, however, allows subsequent retrospective analysis of outcomes, which can yield information and insights into best practice.” Big data can be used to measure performance of nearly every aspect of an O&P business and identify areas or processes that can be improved in a strategic plan, says Tyler Klenow, MSOP, MBA, CPO, LPO, FAAOP, a clinician at Orthotic & Prosthetic Centers Inc., and chair of AAOP’s Outcomes Research Committee. “Predictive analytics will work their way into healthcare exponentially in the coming years and could have a profound impact on our profession and our host institutions,” Klenow says. “Not only is big data able to reactively measure change, but proactively predict when and where deficiencies will occur—effectively allowing us to address issues before they happen. “Typically the data being collected and analyzed is related to the etiology, treatment, and performance of the patient, but also includes administrative information such as demographics, co-morbidities, insurance information,

Kenton Kaufman, PhD, PE

Shane R. Wurdeman, PhD, CP, FAAOP claims data, etc.,” Klenow adds. “The collection of these types of data improves the patient experience by allowing the clinician to take a more holistic approach to care.” While it is clear that a movement toward O&P big data is necessary, there are still some hurdles to clear and obstacles to overcome before the concept is embraced by the entirety of the O&P community. One problem for the O&P field in particular—more so than other healthcare fields—is that facilities are sometimes limited in their ability to gather data, says Hafner. For example, new patients with recent limb amputation start off in a hospital, then transition to a smaller private O&P facility for prosthetic care. “Because those two systems are not always directly connected through their software systems, that makes it really challenging to gather and aggregate data across these systems,” explains Hafner. “We as a profession are now starting to struggle with that,” Hafner adds. “With the new NIH/DoD Limb Loss and Preservation Registry, the challenge is: How do you pull together all this data from across very disparate healthcare systems, analyze it, and then use it to advance the field?”

Areas of Collaboration

As O&P professionals anticipate the debut of the LLPR, individual facilities can start generating a data plan to consistently populate their electronic medical records (EMR) and capture outcome measures, suggests Brian Kaluf, BSE, CP, FAAOP, clinical outcome and research director at Ability P&O. Doing so will reap benefits once the registry becomes reality—but it will also benefit current patients.


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O&P Decision Making One facility that has made inroads in the big data arena is Ability Prosthetics & Orthotics, which has 10 patient locations in the midAtlantic region. Due to its size and its early dedication to capturing outcome measures, Ability now holds enough data to use its big data in a meaningful way, according to Brian Kaluf, BSE, CP, FAAOP, clinical outcome and research director. The facility began aggregating data about seven years ago, and uses two central systems for data collection: its electronic medical record (EMR) system and a separate standalone outcome measures database it developed in 2015. Clinicians are asked to input data during certain episodes of care and to include scores from outcome measurement instruments such as the Amputee Mobility Predictor and similar tests into the database. This facility-wide dataset has grown over time and enables Ability P&O to benchmark patients and provide more meaningful information with regard to patient expectations, given identifying factors such as age, gender, and mobility level, says Kaluf. “We have outcome measure datasets available from before and after providing an initial prosthesis to a recent amputee.” For example, “we can look at data that’s more specific to how an older, transfemoral, female patient scored before and after being fit with a prosthesis, and we can advise patients on what they can expect to achieve,” says Kaluf. The facility’s practitioners have access to automated individual patient outcome reports each time the data is input, displaying benchmarking data to show patients how they have improved—or declined—over time. Ability has found that having data to back up clinical decision making can result in improved clinical encounters, and clinicians also use the data to address patient anxieties about health-related domains. One area where the analysis of outcome measures data has been particularly useful is in assigning the Medicare Functional Classification Levels, or K-levels, for Medicare patients, says Kaluf. While many prosthetists rely on a type of informal decision tree, informed by their own experiences and perceptions, Ability clinicians can now also consider their individual patient’s data and big data aggregated from all Ability patients when assigning a functional level. All such decisions are documented in patient records and automatically compared and interpreted against the facility’s datasets. “This is a much more precise and reliable process,” says Kaluf. “Our functional level assignments are now data-informed. We can actually predict the change in functional ability a patient is likely to experience when they get their prosthesis. … Our patients get much better care and get a much more appropriate functional level assignment, supported by the data.”



Brian Kaluf, BSE, CP, FAAOP Small facilities can take a first step by asking colleagues for advice. “Start small,” says Hafner. “You don’t have to collect data on every person, every time—but maybe for your lower-limb prosthetic patients, try to collect one or two outcomes measures. Find a way to collect that information, store it in a way that allows you to look at it—not just at the individual patient level, but across the patients that you see. And then, once you have the data, you can see what kind of story it tells.” Not only will facilities find value in the process, but many patients will appreciate being able to track their changes over time, says Hafner. Facilities that have multiple locations can take the data collection effort to the next level, by aggregating patient data and certain outcome measures across all patient locations to assist in their clinical decision making and research initiatives—a model embraced by Ability P&O (see sidebar, DataInformed O&P Decision Making). Hanger Clinic is evolving toward full incorporation of outcomes within its standard of care, according to Wurdeman—and one byproduct of this effort has been the “accumulation of common outcome measures across thousands of patients,” he says. “Given this information, Hanger Clinic’s Department of Clinical and Scientific Affairs saw the opportunity to extract information from this to yield insights into improved clinical care.” Taking data collection one step beyond the company-wide level is capturing data across the field as a whole, Hafner says. “What if we brought together the clinics, and the manufacturers, and the hospital systems? Theoretically, the end goal is to have enough data across enough people and


systems that we can use that information to better inform our clinical practices, to better establish benchmarks for ourselves and our industry, to advance knowledge in our understanding of O&P science, and hopefully to then review, revise, and even inform new policies to provide better care.” For a more collaborative approach to emerge, the O&P community will have to identify common data elements to collect. “We need to come together and have discussions about what we universally value,” Hafner explains. “And it doesn’t have to be that everybody collects all of the same data—there’s no ‘one-size-fits-all’ outcome measure that’s going to be ideal for everyone. But we should all be collecting some of the same data.” One of the goals of AAOP’s Outcomes Research Committee is to identify common data elements that O&P facilities may want to start collecting. According to Klenow, who chairs the committee, the committee members are “developing a set of recommendations for outcome

measure utilization in clinical practice, which we call the ‘outcome measure toolkits.’” These toolkits will serve as the official recommendation by the Academy to its membership, to the O&P profession, and to the entire rehabilitation community, Klenow says. “The recommendations are according to intervention type. The first toolkit, [to be] released later this year, will be for lower-limb prosthetics, followed by upper-limb prosthetics. We then hope to begin forming recommendations for orthotic devices as well.”

The Registry Takes Shape

As more facilities buy in to the idea of big data and begin to collect common data elements, the next step will involve benchmarking across the profession—and the establishment of the LLPR, says Klenow. “This process involves the comparison of our data to that of other health professionals and clinical populations. This means our practitioners measured against other professionals, our businesses against other systems, our treatments against

other modalities, and the outcomes of our field against those of others. These comparisons will likely be incorporated into value-based reimbursement models in the near future,” he predicts. Ultimately, “the analytical capabilities of the registry will make it possible to examine this data and provide insight for forming clinical practice guidelines that yield optimal patient outcomes,” says Kaufman. The initial stages of developing the registry are currently under way. “We have begun pilot studies with the American Joint Replacement Registry and two hospitals to assess the feasibility of collecting the data,” using an initial set of data elements to be gathered, says Kaufman. “This effort will be expanded next year to begin collecting data from prosthetists, other clinical providers, and patients. We will use the ISPO Scientific Committee recommendation for the minimum dataset to improve how technical and clinical reports are designed and reported to the prosthetic community.”


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Expanding the O&P Research Well While more informed clinical decision making and improved quality of life for patients are the main goals of healthcare data initiatives, contributing to peer-reviewed research for the betterment of the field is a secondary goal. Both Ability Prosthetics & Orthotics and Hanger Clinic have been involved research studies that leverage the outcome measures data they have collected at their facilities. “It’s hugely important to share summary statistics with the profession at large,” says Brian Kaluf, BSE, CP, FAAOP, clinical outcome and research director at Ability P&O. “We recognize that other facilities may be smaller and may not be able to” aggregate as much data, says Kaluf. “We are proud to help fill the data gap.” Hanger Clinic’s Department of Clinical and Scientific Affairs recently published its first series of analyses of the dataset of outcomes in its “Mobility Analysis of AmpuTees,” or MAAT series. The MAAT series covers multiple analyses focused on functional mobility for individuals with lower-limb amputation, according to Shane R. Wurdeman, PhD, CP, FAAOP, director of clinical research, Hanger Clinic Department of Clinical & Scientific Affairs. And future updates to Hanger Clinic’s previously published clinical practice guidelines will incorporate the MAAT studies, as well as other studies that are being conducted by Hanger Clinic’s Department of Clinical and Scientific Affairs.

Over the next four years, the goal for the registry “is to bring together all the individual clinics and providers [who are] willing to share some of their data … and to make sure that data is valuable and useful to everybody,” says Hafner. He believes this project has the potential to bring the profession together, with everyone contributing data to the larger pool—“as long we continue to move toward it, and people understand what the value is.”

Benefits and Challenges

One of the central benefits being seen by those facilities currently collecting outcome measures data is an improved patient-care experience, says Klenow. “Some information about the patient can only be discovered or elucidated through administration of outcome measures,” he says. In addition, this information “can help 30


company executives … by allowing the measurement and improvement of several aspects of practice management,” including clinician productivity and efficiency, patient satisfaction, and administrative productivity. At Hanger Clinic, the data currently being collected is used for “support,” rather than “enlightenment,” explains Wurdeman. “We are using the information within our outcomes database to delineate observed realities versus previously what could only be considered reasonable assumptions.” But he cautions against relying on big data to guide strategic planning. Klenow notes that aggregated data at the facility level also can help individual practices in providing supporting documentation to other healthcare professionals. There is an “increasing popularity of performance reports to referral sources as a

Tyler Klenow, MSOP, MBA, CPO, LPO, FAAOP marketing tool to keep physicians and therapists involved in the continuing care of their patients,” he says. And aggregated performance data also can be used in contract negotiations “to show an insurer or medical system the superior level of care being provided,” Klenow adds. “Larger companies are able to aggregate claims data to combat unfair denial patterns. The possibilities are endless, but ultimately show the advancement of the field and the progression of the practitioner from a device provider to an authentic medical professional.” But the concept of a national registry, where the entire O&P community is contributing data, also brings with it some hard questions—questions that must be considered as the registry project moves forward. How the data gets put into a shared system may pose a challenge, says Hafner. “Is it mandatory? Is it voluntary? How do you get patients, practitioners, and practices to want to share their information?” Another question relates to ownership of the data. “That data is very powerful, and used appropriately, it can help establish benchmarks for our field, characterize what our best practices are, inform research and our scientific understanding of the issues, and help guide and inform public policy,” Hafner says. “But used inappropriately, it can also do the opposite. It can set us backwards and maybe restrict access to technology, which we really don’t want to happen. So, we have to make sure that we’re collecting the right kinds of data, that we’re using that data appropriately, and that we’re monitoring it to be sure that people are representing that data fairly and accurately.”


Wurdeman notes that access for such a powerful data repository “needs to be controlled in a manner that all contributing can have access to the results of analyses—but caution should be taken about allowing access for analysis, given the complexities of this activity.” Hafner suggests there may need to be an oversight panel tasked with evaluating whether those who request access to the data have a thoughtful plan on how they intend to use it. “We just can’t open it up to anyone, in my opinion. There has to be some sort of process by which requests to access the data are reviewed and considered carefully.” It’s also important to recognize that big data can be subject to biases—“both in how it gets in, and in how it is extracted and analyzed,” says Hafner. “These large datasets can be data mines, where people can go looking for data to tell a story they’ve already decided to tell, rather than thoughtfully evaluating the data to see what it might have to say. For this reason, I think we have to be careful not to let people misuse the data.” In addition, concerns regarding security arise when it comes to management of big data, according to Klenow. As facilities turn to outcome measures, dashboards, and analysis of data, there is an increased risk of misuse, abuse, or acquisition, he explains. “It seems every other story on the evening news is a data breach … the foremost issue is macro-security of these large datasets.” All of these issues will need to be examined more closely as increasing numbers of O&P companies collect data and begin sharing information as part of the LLPR project.

Embracing Change

As more O&P facilities commit to adding to the greater O&P data pool, clinicians can expect both rewards and minor setbacks. “Creating a culture of outcomes collection can be challenging,” cautions Phil Stevens, MEd, CPO, FAAOP, director, Hanger Clinic Department of Clinical and Scientific Affairs. “It’s not an area that has been stressed

Manufacturers Do Their Part Stakeholders from various corners of the O&P world need to work together to ensure clinicians are capturing outcome measures and populating databases, says Mahesh Mansukhani, chief executive officer of WillowWood. “When I think about WillowWood manufacturing medical devices, we need to hold ourselves accountable to amputees, clinicians, and payors,” he says. O&P facilities should focus on aggregating data that will improve outcomes in four areas, suggests Mansukhani: patient compliance, indication-specific outcomes, co-morbidities, and activities of daily living. WillowWood takes these factors into account when designing any new products, he says. “When we bring new products to market, we’ll have done the research” in the development phase to ensure the product will perform as needed, then clinicians will be able to perform outcomes tests to show benefits for the patients who use the devices. Mansukhani encourages O&P facilities to commit to conducting outcomes testing and aggregating data. “If they can unequivocally show better outcomes for their patients, then you can go to insurance companies and market that, and you can go to patients and market that,” he says.

historically, so it takes time and effort to help clinicians integrate outcomes collection into the clinical workflows. But it’s a vital part of the process.” Hafner notes that data is just one contributing factor to improving patient care. “Combine data with experience with the empathy of being a good practitioner, and I think that data will be very useful. I believe in the idea of a data-informed practice—one where people are collecting information and using it to guide their clinical decisions in a logical way. “Everyone is a small piece of the larger puzzle, as we try to ultimately aggregate all of this information,” Hafner adds. “None of us can answer some of these questions individually, but together we can.” Like it or not, value-based reimbursement models are coming, concludes Klenow. “Big O&P data allows us to form our own narrative about the delivery

Phil Stevens, MEd, CPO, FAAOP models of our care in the future—as opposed to them being dictated to us again,” he says. “We need to perform and disseminate economic and performance analysis of our devices and care models so we have a base from which to combat sweeping governmental and regulatory changes in the future.” Christine Umbrell is a contributing writer and editorial/production associate for O&P Almanac. Reach her at cumbrell@contentcommunicators.com. O&P ALMANAC | JULY 2019




RURAL How some O&P professionals are adapting their practices to meet the needs of patients in under-served areas

NEED TO KNOW • Nearly one-quarter of rural Americans feel they lack access to quality healthcare services, and nearly half of rural Americans with disabilities have been unable to get healthcare when needed at some point, according to recent studies. • Many orthotists and prosthetists located in rural areas see patients who travel long distances—prompting some clinicians to adopt treatment strategies that involve telehealth, satellite offices, and mobile care.



• Taking time to educate patients about their care and compliance can help ensure patients wear their devices as instructed and return for follow-up visits. • O&P facilities in less populated areas face challenges in recruiting clinicians willing to live away from big cities—so young professionals should be encouraged to consider working in these areas.

PHOTO: Getty Images

• O&P clinicians get creative when dealing with patients who require specialized O&P devices—such as rugged prostheses adapted for farm work or manual labor and custom orthoses designed for durability.

• Being open to compromise and well-prepared—with mobile toolkits—helps clinicians provide better care to their rural patients.



PHOTOS: Mark Gorman, CPO

Mark Gorman, CPO, for a prosthetic leg, but he had a very specific need. He works on a chicken farm, which has electric wire running around the perimeter about 5 inches off the ground. While the patient knew how to weave through the chickens and wire to avoid being shocked, now that he has a prosthetic leg, he’s worried he won’t be as agile. His main concern is that the metal stem increases his risk of an electric zap. So, the patient wondered if the metal pieces could be covered. Gorman had to brainstorm for a solution. He wrapped pelite-type foam around the stem of the prosthesis to insulate the leg. He wasn’t positive it would work, but he allowed the patient to try the prototype out on the farm. For Gorman, this story perfectly illustrates what it’s like to work with some of his patients in West Virginia. While the main office of Morgantown O&P Center is in the state’s fourth largest city—Morgantown, which is also home to West Virginia University—he treats patients from all over the state. About half of his patients live in rural areas. That means some people drive up to five hours from hidden hollers tucked among the mountains for their appointments. While others have shorter commutes, Gorman’s goal for treating people who travel from outside the city is the same: to provide care for them in an efficient way that minimizes their need to travel to the office. To do this, Gorman needs to be flexible and innovative, regardless of their need level. “I am the jack-of-all-trades, master of none,” he says. “Sometimes in the big city you have to specialize to create your niche … we truly like the whole spectrum. We see acute care to nursing home. And we see infants to old folks. We like that—to be able to do all things.” There’s only about 25 certified clinicians in the state, which has a population of approximately 1.8 million people. Many of the CPOs work with the universities, participating in research and helping the

Mark Gorman, CPO

Gorman encountered a bear on his way to see a patient in West Virginia. medical center patients. But that limits the number of O&P professionals available to care for residents who live in the isolated corners of West Virginia. So, Gorman must be creative to help ensure those patients receive consistent care. That may involve using technology for consults or figuring out how to make a prosthetic limb more durable for farm or mining work. “If people have issues, I do not hesitate to tell them to send me a picture. We can save them some time and energy to instruct them [on] how to do something,” he explains. Coaching people through minor adjustments saves a patient from a long trip, while making sure they are using a device that works properly and isn’t hurting them. But Gorman really needs to know his patients and understand whether they have the ability to make the adjustments. There are certainly patients who aren’t handy with wrenches and pliers, and he knows he can’t talk them through an adjustment. In those cases, one of his facility’s clinicians will try treating

them at one of the branch offices located in Clarksburg, West Virginia, or Deep Creek, Maryland. If a patient is unable to make it to one of those offices, Gorman’s staff works with the individual to schedule an appointment when he or she is in Morgantown for other medical appointments. “We do home visits, but we try to limit them,” Gorman says.

Where Healthcare Is Inconvenient

Providing any sort of medical care to rural populations can be a challenge. Pew Research Center recently studied Americans’ proximity to hospitals and found that 23 percent of rural Americans feel they lack access to quality healthcare services. And it’s no wonder: the U.S. Government Accountability Office reported that between 2013 and 2017, 64 rural hospitals were shuttered. That’s twice the number of closures than occurred in the previous five-year period. Such closures mean patients must travel further distances for any sort of care. O&P ALMANAC | JULY 2019


Many patients in rural areas— defined by the U.S. Office of Management and Budget to be anywhere that’s not part of a Metropolitan Statistical Area, a geographical region with a relatively high population density at its core and close economic ties throughout the area—are challenged by reduced access to healthcare and insufficient funds to pay for care. In a recent NPR survey, nearly half (48 percent) of rural Americans who live with a disability reported not having been able to get healthcare when they needed it at some

point in recent years—and 53 percent reported having problems paying medical bills (see Numbers on page 10). Healthcare facilities tasked with treating patients in these rural areas face challenges of their own, in terms of recruiting professionals to work in remote areas and being able to connect with patients who need their services. For example, Alpine Medical in Cody, Wyoming, which provides orthoses and prostheses to patients living in the northwest corner of the state, is currently without a staff CPO, according to its manager, Joni Bennet. The office had a CPO on staff—but he resigned about a month ago, and the facility has not hired a replacement. “We cover probably about 1,000 miles worth of outlying little cities,” Bennet says. “It is hard to find [employees].” For now, the facility plans to provide patients with off-theshelf devices when appropriate—and direct patients who require custom devices to CPOs in Billings, Montana, which could be up to a four-hour drive. Unfortunately, some patients

Charles W. Kuffel, MSM, CPO, LPO, FAAOP



A Flexible Approach to Patient Care Making sure that patients receive the care they need requires flexibility, especially when a rural population needs devices that can withstand manual labor and farm work. Arise Orthotics & Prosthetics Inc., headquartered in Spring Lake Park, Minnesota, sees both local patients as well as individuals living in the northwest part of the state, which includes a lot of farm land. Charles W. Kuffel, MSM, CPO, LPO, FAAOP, president and clinical director of Arise, has noted many differences in treating the two populations: People need simple, durable prostheses in rural areas, he finds. While a microprocessor knee might really help a farmer, if it breaks down during harvest season, the farmer might have a knee that he can’t use when he needs it most. The farmer may simply not have the time or ability to see his clinician for replacement componentry during planting or harvesting seasons. “Farming communities are very hard on their prosthetic devices,” Kuffel says. “I keep them as simple as possible.” On average, patients travel 60 to 80 miles for prosthetic care, so Kuffel makes a lot of house calls. He’s fitted someone in the back of a McDonald’s and in the middle of a field. Like Kuffel, Dara Ross, CPO, spends a lot of time on the road to meet her patients’ needs. Ross works for Prosthetic & Orthotic Institute Inc. in Rock Hill, South Carolina, which is located close to Charlotte, North Carolina. But about 60 percent of her practice actually occurs in a satellite office in Lancaster, South Carolina. People travel at least 30 miles to see her—and many travel even further, upwards of 45 minutes to an hour, to go to a hospital. Like clinicians treating similar populations, Ross believes that if she did not see patients at the rural location, many people wouldn’t receive treatment. “There wouldn’t be any access,” she says. “We are the only ones going out to these communities.”

PHOTOS: Charles W. Kuffel, MSM, CPO, LPO, FAAOP

Kuffel travels to see patients in rural parts of Minnesota—and while he doesn't normally fit animal prostheses, he made an exception to assist a farmer whose donkey was missing a leg.

may delay care when the drive is so long, says Bennet.

CL MB The path to the top isn’t always easy. But at Hanger, no one has to do it alone. And there’s no limit to how high any of our team members can climb. Hanger is the clinical leader in orthotic and prosthetic care because we hire the best and the brightest. We provide vast resources, opportunities for career advancement, and the most innovative technology in our field to help them do what they do best: care for our patients. We’re passionate about the life-changing, fulfilling work we do to empower our patients to take on life’s challenges with increased mobility, independence and self-confidence. We know this important work starts by supporting our employees. Empower your career. Apply today and climb higher at Hanger.


Hanger, Inc. is committed to providing equal employment to all qualified individuals. All conditions of employment are administered without discrimination due to race, color, religion, national origin, sex, age, disability, veteran status, citizenship, or any other basis prohibited by federal, state, or local law.

work. It was going to be disgusting.” She worked collaboratively with the patient and his physician to create a solution, which included a closed-toe shoe. But she also taught him how to weatherproof the sock for walking outside and explained the risks of unhealed ulcers to ensure the patient understood why wearing the shoes was critical. “In the end, he understood and he compromised,” she says.

Fostering Relationships

Dara Ross, CPO



serious ulcers on his feet who lived in a trailer surrounded by mud and gravel paths. His doctor provided open-toed cardboard and fabric braces to help his feet, but the man didn’t want to wear them, given his environment. “He was saying, ‘It is ludicrous that they want me to be in these fabric, open-toed shoes with cardboard,’” she recalls. “It just wasn’t going to

PHOTO: Getty Images

Despite her best efforts, many of her patients arrive at the facility after having delayed seeking the necessary care. For example, one of Ross’s patients—who needed an anklefoot-orthosis but was unaware of the solution—created an intricate system of bungee cords to act as pulleys to help lift his foot. He simply did not realize that a CPO could provide him with a device to make life easier. After meeting with Ross, he was fit with an appropriate orthosis—and his mobility has greatly improved. She tries to remind patients that their own short-term fixes and improvisations may serve them in the short term, but they may contribute to greater long-term problems—“things you can’t fix 10 years down the road because they didn’t get the care they needed” at the outset. Ross has found that she needs to be innovative. Many patients lead lives that require modifications to their devices so they can use them effectively. She remembers visiting one patient with

PHOTOS: Dara Ross, CPO

Ross travels down long, remote roads in North Carolina to see patients.

Being open to compromise and well-prepared helps clinicians provide better care to their rural patients. Many clinicians find that making concessions with patients may be necessary to ensure they are wearing their device appropriately and at the prescribed frequency. Mark Skadsen, CO, has found that getting patients to be compliant often involves a lot of discussion. “You spend more time educating the patient. That is more challenging,” says Skadsen, who is based in Sioux Falls, South Dakota, and conducts outreach to patients in Pierre, the state capital, about 231 miles away from his home office. Gorman says that knowing how to approach each patient in language that makes sense goes a long way in ensuring patients understand wear instructions and commit to compliance. “I can [either] use my biomechanical words that I will use intra-professionally” or speak in the local vernacular, says Gorman. The latter approach gets better results.

PHOTOS: Dara Ross, CPO

Ross brings a well-stocked toolkit wherever she goes. Many clinicians in rural areas have learned to “always be prepared” in case they need to make quick fixes in unusual circumstances. Ross keeps a travel bag loaded with tools handy at all times, enabling her to make adjustments on the fly. Her bag includes many items that are useful in an emergency: a phone charger, Phillips-head and flat-head screwdrivers, pliers, a heat gun, razor blades, Velcro, and proof of delivery and other required documents that may need to be filled out. “It’s anything I need for a minor adjustment or an alignment on the road,” she explains. While being malleable helps Ross and her peers meet their patients where they are, there are times when an office visit is required—for example, when a patient should work on the parallel bars or when nonportable equipment is needed for a fitting and modification. “Many times, I can [visit patients in their] home, but sometimes I need the tools or the parallel bars to keep them safe,” Ross says.

She has found it’s easier to encourage patients to schedule office visits when she is extremely specific in her explanation of what the visit will entail. “Always give someone a reason why they need to come into the office,” Ross says.

Providing Appropriate O&P Care

One worrisome trend that has manifested in some areas of the country is the rise of physical therapists or doctors trying to provide orthotic and prosthetic care to rural patients. Kuffel has observed that some healthcare professionals who are not certified in orthotics and prosthetics have tried to treat patients. Individuals who are not specifically trained to provide O&P services “will dip their toes into orthotics and prosthetics—and then they will call us to rectify the problem,” Kuffel explains. But at that point, Kuffel can’t bill for the services because the other provider already did so. “We can’t capture the revenue,” he says. This problem highlights a need for more CPOs and better education, Kuffel suggests. “Often physicians and therapists in the rural areas will provide the care in its entirety until there is a problem. They are providing

a valuable service to those in need of O&P care—however, they are not usually specifically trained in O&P care,” he says. “This is why you really need to rely on a certified prosthetist.” Given the dwindling number of rural hospitals, the financial challenges facing many patients in under-served areas, and long travel distances between facilities, healthcare in general is a problem for many in remote parts of the country. O&P professionals do their best to be responsive, innovative, and accommodating, when possible, to ensure optimal patient care in less-thanideal conditions. But in some areas, there is a definite need for more certified clinicians to treat this challenging—but grateful—patient population. “The take-home message is there are not enough orthotic and prosthetic providers,” Kuffel says. As young clinicians graduate from O&P schools and become certified, they should consider branching out to meet the needs of rural Americans. Those with experience treating this population find it to be interesting work—and truly rewarding. Meghan Holohan is a contributing writer to O&P Almanac. O&P ALMANAC | JULY 2019





Join your colleagues in San Diego and immerse yourself in O&P education featuring practical takeaways and cutting-edge research

NEED TO KNOW • A balance of innovative research and easy-toimplement clinical and business strategies will be presented during the educational sessions at the 2019 AOPA National Assembly in San Diego, September 25-28, presented in partnership with the California Orthotic & Prosthetic Association. • Clinical sessions will focus heavily on evidence-based research and have been designed with a multidisciplinary approach, featuring instruction from the perspectives of O&P clinicians, physicians, academic researchers, and therapists.



• Business education sessions will be targeted toward business owners and managers, practitioners, and distributors, with topics centering on low-cost business strategies, private insurance, veteran care, and more. • Technical education programming will center on instruction in current techniques as well as comprehensive reviews. Several sessions will include discussion of additive manufacturing. • The dedicated pedorthic track will focus on the diabetic foot, with podiatrists, surgeons, chiropractors, orthotists, and pedorthists leading the sessions.



through this year’s educational sessions at the AOPA National Assembly in San Diego—an emphasis on useful, real-world information. “We want our takeaways to be key and practical,” says Elizabeth Ginzel, CPO, LPO, co-chair of the Business Education Workgroup.

Michael Oros, CPO, LPO, FAAOP This aim is echoed by Michael Oros, CPO, LPO, FAAOP, who co-chairs the Clinical Sessions Workgroup. “We tried to strike a balance between the academic and the ‘take-things-backwith-you-on-Monday’” approach, he says. In all four tracks—clinical, business, technical, and pedorthic— presenters will share information you can bring back to your facility and immediately put to use.

Improve Patient Care With Clinical Education

You can get a head start on this year’s clinical education sessions by attending a pre-show hands-on workshop Tuesday morning, September 24, “Muscle Tone and Hypertonus— Assessment and Relevance to Orthotic Management,” presented by Beverly Cusick, PT, MS, NDR, COF/BOC. “This is an excellent session for both orthotists and therapists interested in managing children with pediatric neuromuscular disorders,” says Oros. The full clinical education track begins on September 25 and features a multidisciplinary approach, with symposia led by presenters with a variety of perspectives, including O&P practitioners, physicians, academic researchers, and therapists. Oros and his co-chair, Charles Kuffel, CPO, LPO, FAAOP, designed clinical education morning sessions that tackle broad topics, with more specialized orthotic and prosthetic topics in the afternoon.

The first morning session, on Thursday, September 26, is “Outcomes and Evidence-Based Practice in O&P: How Are You Documenting Value in Your Clinic and Using It To Improve Reimbursement?” The interactive session combines both clinical and business education, as presenters Kristin Carnahan, CPO, FAAOP; Chad Duncan, PhD, CPO, CRC; Russ Lundstrom, MS; and Matthew Major, PhD, address how to implement outcome measures into your practice. Charles Kuffel, CPO, LPO, FAAOP The Thranhardt Lecture Series presents consecutive award-winning talks from 8:30 to 9:30 a.m. on Thursday, September 26. Tiffany Graham, MSPO, CPO, LPO, and Kelly Millay, MPO, will review the effect of such factors as prematurity, torticollis, age, and initial head shape on asymmetrical brachycephaly

treatment outcomes. Andreas Hahn, PhD, MSc, will discuss using health economic instruments to demonstrate how providing prosthetic services to diverse, large patient populations can be cost-effective. After lunch, concurrent symposia look at “Contemporary Perspectives on Low Back Pain in the Population With Limb Loss” and “Orthotic Management of Traumatic Spine Injury,” both featuring multidisciplinary presenters. Following these sessions, from 3:15 to 5 p.m., is a symposium on osseointegration that convenes O&P practitioners, surgeons, and academic researchers to discuss osseointegrated prosthetic options that have been approved by the U.S. Food and Drug Administration and are available in the United States. Running concurrently will be a Free Paper Session featuring five shorter educational presentations on lower-extremity orthotic management. Another Free Paper Session on osseointegration rehabilitation follows at 5 p.m., highlighting case studies and specific research on the topic. O&P ALMANAC | JULY 2019


On Friday, September 27, clinical education and pedorthics meet in the session, “The Diabetic Foot From the Outside In,” presented by David Armstrong, DPM, MD, PhD; Judith F. Baumhauer, MD; and Erick Janisse, CO, CPed. In addition to analyzing trends, statistics, and forecasts, presenters will offer creative, conservative strategies designed to prevent repeated surgical interventions. Concurrent symposia on multiarticulating hands and treatment of pediatric cerebral palsy begin at 1 p.m. Afterward, attendees may find it hard to choose among three concurrent Free Paper Sessions at 3:15 p.m., with brief presentations on “Improving Outcomes and Quality of Life for the Lower-Extremity Amputee,” “Pediatric Orthotics From Head to Toe,” and “Treating the Foot and Ankle.” Saturday sessions feature a two-part First Stride Gait Training Clinic on “Prosthetic Balance Training.” “These clinics focus on how to do introductory physical therapy and gait training for new amputees,” explains Oros. “Clinicians will be able to immediately apply what they’ve learned to their daily practice.” Another option at that time is a symposium called “The Role of Microprocessor-Controlled Orthoses: An Update on Current Experiences and Upcoming Projects,” which will be presented by Malte Bellmann, PhD, CPO; Thomas DiBello, CO, LO, FAAOP; Andreas Hahn, PhD, MSc; Arun Jayaraman, PT, PhD; Andreas Kannenberg, MD (GER), PhD; Ken Kaufman, PhD, PE; and Jason Wening, MS, CPO, FAAOP. Presenters will review existing technology and compare the new C-Brace with conventional knee-ankle-foot orthoses, both in terms of application and effectiveness as well as medical necessity. Free papers on devices for lowerextremity amputees and a symposium on upper- and lower-extremity prostheses that restore sensation to amputees also are scheduled for Saturday. The clinical sessions will wrap up as they began, with a hands-on workshop—this time a session on 40


“Fabricating and Aligning Prostheses for Elite-Level Amputee Runners,” led by Stan Patterson, CP. This session features practical methods and devices to help athletes succeed and features patient models Scout Bassett, a Paralympian, and bilateral amputee Marko Cheseto, who this year set a world record at the Boston Marathon.

Boost Productivity With Business Sessions

When putting together the business education sessions, co-chairs Ginzel and Kimberly Hanson, CRPH, director of reimbursement, North America, at Ottobock, set a goal: Attendees should go home ready to put what they have learned into practice.

Elizabeth Ginzel, CPO, LPO “Our overarching theme is to bring timely information to people— trends and facts from key leaders and decision makers in the industry,” including representatives from the U.S.

Kimberly Hanson, CRPH

Department of Veterans Affairs (VA), Medicare, and the insurance industry, says Hanson. She and Ginzel monitored presentations carefully to select those that would present unbiased information and tangible steps to implement new strategies. On Thursday, September 26, several “Top 10 Takeaway” sessions will offer attendees a minimum of 10 takeaways and objectives. During one of these presentations, Rick Riley, chief executive officer, Townsend Design/Thuasne USA, will present “Top Low-Cost Business Strategies for O&P Clinics.” “Rick can help facilities identify and understand their market, so they know whom to target and what approach to take,” Ginzel says. Other “Top 10 Takeaway” sessions deal with producing highquality and compliant documentation and understanding medical necessity definitions and documentation.

Special Education Events Add these “can’t miss” educational opportunities to your itinerary at the 2019 AOPA National Assembly in San Diego.

Pre-Show Hands-On Workshop: Muscle Tone and Hypertonus— Assessment & Relevance to Orthotic Management Tuesday, September 24, 10 a.m. – 4:15 p.m. Take part in this workshop for important orthotic information that will clarify the currently accepted definition of “human resting lower-limb muscle tone” in terms of the length-tension relationship, with particular attention to the hamstrings and ankle plantarflexors. Instructors also will relate movement strategies to the development of typical ankle function and equinus deformity and review clinical assessment procedures for hamstrings length and ankle dorsiflexion range of motion in detail. Tickets are $75 per person. Space is limited.

First Stride Gait Training

Co-Sponsored by OPAF Saturday, September 28, 9 – 11 a.m. and 1 – 5 p.m. Attend this program and take away information you can apply to your daily practice. The session begins with a review of relevant outcome measures that guide assessment and treatment in the amputee population. The course continues with a review of important concepts in normal and pathological human locomotion. All lecture topics are applied with an afternoon hands-on lab that includes local community members as course participants.

O&P Expo Day

Saturday, September 28, 9 a.m. – Noon Rehabilitation partners, patients, families, and the community will join O&P professionals in the exhibit hall for a morning of learning and collaboration. All Assembly participants are welcome to invite their referral sources, physical therapy partners, patients, families, and other members of the rehabilitation team for free Assembly passes to the exhibit hall. All must register and obtain a badge to enter the exhibit hall.

Post-Show Hands-On Prosthetic Clinic: Fabricating and Aligning Prostheses for Elite-Level Athletes

Sunday, September 29, 9 a.m. - Noon Stay an extra day and take part in a demonstration of fabrication and alignment techniques to create elite-level sports/running prostheses for athletes. Study differences in components and various selection theories, and learn to use video analysis and other methods to determine correct weight line distribution and make modifications. Marathon record-holder Marko Cheseto and Paralympian Scout Bassett will serve as patient models. Tickets are $75 per person. Space is limited.



Contests Who’s ready for a competition? Consider the following opportunities to compete against your colleagues for prizes and bragging rights. Technical Fabrication Contest Start practicing! This year’s technical fabrication contest will feature a timed competition on the exhibit hall show floor. Sign up, strut your stuff, and show the profession that you are the best technical fabricator in the O&P profession. Winners receive bragging rights and cash prizes ($500 prize for the first-place winner and $200 for the runner-up). There is no charge to participate. All National Assembly registrants may participate unless they are a judge, work for a contest sponsor, or are on the National Assembly Planning Committee or AOPA Board of Directors.

Step It Up Challenge

Start walking and take part in a three-day Step It Up Challenge! Participants can track their steps via phone, app, fitness tracker, pedometer, etc. Participants must post a picture of their daily steps by 7 p.m. each day in the Activity Feed of the AOPA 365 app or present their data to the Step It Up race headquarters, located right outside the exhibit hall. Sign up for your chance to win daily cash prizes! Exhibitors can participate but will not qualify for prizes. Sponsored by MD Orthopaedics.

Student Poster Award

Calling all students and residents—gain national recognition and advance your career. Enter to win an award: • The Student-Resident Poster Award honors two meritorious scientific papers submitted for presentation as a poster at the AOPA National Assembly. • The Otto and Lucille Becker Award will be presented for the best orthotic abstract. • The Edwin and Kathryn Arbogast Award will be presented for the best prosthetic abstract. For complete rules and to submit your abstract, visit bit.ly/2019srposter. 42


Ginzel highlights sessions of particular note, such as Thursday afternoon’s “Private Insurance & the Industry— Working With Private Insurance: How To Make What’s Important to You, Important to Them,” presented by Dan Oftedahl, national head of transformative markets, Aetna. “Dan has more than 25 years of experience in the industry and can offer an interesting outside perspective from a big insurer,” says Ginzel. The presentation by Jason Highsmith, DPT, PhD, CP, FAAOP, “VA Updates & Highlights,” is sure to be well received, predicts Ginzel, as facilities want to stay abreast of ongoing reimbursement changes and will benefit from learning about recent activities at the VA. Highsmith became national program director, national director for the Clinical Orthotist and Prosthetist Service, for the Veterans Health Administration Office of Rehabilitation and Prosthetic Services last October, and will speak from his vantage point as a VA official with a background in O&P.

Brad Mattear, LO, CPA, CFo

Tackle Fabrication Challenges With Technical Education

The technical education program will appeal to a healthy balance of technicians and fabricating practitioners, and anyone who wants to learn about a specific technique, says Brad Mattear, LO, CPA, CFo, who chairs the Technical Education Workgroup. “A good number of clinicians still want to fabricate,” he notes, “and we want to offer them both current techniques— what we call Current Concepts in Fabrication 2.0—as well as a comprehensive review.” This year, for first time, planners decided to weave additive manufacturing, or 3D printing, into several presentations, rather than dedicating an

entire day to the subject, in an effort to give attendees increased access to the information. “We’ll be exposing more and more people to additive manufacturing, and we’re excited about that,” says Mattear. On Saturday, September 28, a workshop by Jeffrey Erenstone, CPO, will guide participants step-bystep through the process of designing and fabricating a 3D-printed device. “Participants will leave with a file they can print and then create their own device,” Mattear says. One featured session, “PosteriorMounted Feet in Prosthetics,” led by Sam Hale, CPO, at 9:30 a.m. on Thursday, September 26, looks at what a skilled practitioner working with a technician must consider to achieve proper fabrication and, most important, correct alignment. Also new this year is a presentation by Jacob Keough, CO, “Lamination Techniques for Custom Orthoses,” which deals with composite construction. “This is an advancement from thermoplastic, which is exciting for orthotists and technicians alike,” says Mattear. Keough will discuss the basics of design, materials, and production that enable clinicians to control costs and improve patient access to advanced devices. Additional afternoon sessions on Thursday include “Mechanical Performance of Textured 3D-Printed Prosthetic Sockets,” a study presented

by Julia Quinlan, PhD, and a presentation by Dustin Kloempken that examines how facilities have implemented technology to better serve patients and attract talent. With the rapid advance of technology, some technicians may be concerned about its effect on their careers. Steve Hill, BOCO, CTPO, will discuss the role of today’s technicians and explore how they can advance their skill set to accommodate new methods and materials. “By elevating their knowledge, today’s technicians will continue to be relevant in the next 20 years,” says Mattear.

Dennis Janisse, CPed

Focus on Feet in Pedorthic Sessions

This year’s focus in the Pedorthic Education Program is the diabetic foot. “The number of people with diabetes is escalating at an epidemic rate, and it’s a major issue all over the world,” says Dennis Janisse, CPed, chair of the Pedorthic Education Workgroup. “It was time this year to get back and focus on this area,” explains Janisse, adding that the speaker list

will include specialists in podiatry, surgery, chiropractic, orthotics, and pedorthics. Attendees will want to make time on Friday morning for “The Diabetic Foot From the Outside In,” described on page 40, followed by three consecutive afternoon pedorthic sessions. First, Armstrong, a professor of surgery at the University of Southern California, will present “Diabetic Foot in Remission.” Armstrong makes a case for using the term “remission” rather than “cure” to better reflect the reality of recurrences and need for frequent follow-up. He will discuss standard approaches and advances in mechanics, medicine, and surgery that can help facilitate ulcer-free days. Katia Langton, DC, CPed (C), brings a unique perspective to the diabetic foot in her session, “Is It Lumbar Spinal Stenosis or Diabetic Neuropathy—Or Both?” “With her chiropractic background, Langton explores things she sees that we’re not used to when diagnosing debilitating foot complications,” Janisse says. In addition, Judith F. Baumhauer, MD, a foot and ankle orthopedic surgeon, will discuss the team approach to managing the diabetic foot. Teamwork is indispensable in addressing diabetic foot complications, such as Charcot arthropathy, ulcers, and amputation, according to Baumhauer.

Take Part in AllInclusive Education

The sessions described above are just a small sampling of the many choices in education that will be available in San Diego come September. This year’s AOPA National Assembly will offer both practical information and evidence-based education to attendees. From cutting-edge clinical presentations to productivity-focused business sessions to the latest technical and pedorthic offerings, the curriculum in San Diego will truly offer something for everyone. Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net. O&P ALMANAC | JULY 2019



Proving Delivery Adhering to Medicare’s requirements and documentation guidelines for delivering O&P items

Editor’s Note: Readers of Compliance Corner are now eligible to earn two CE credits. After reading this column, simply scan the QR code or use the link on page 46 to take the Compliance Corner quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.









This month’s Compliance Corner has been written by members of the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Comprehensive Error Rate Testing (CERT) Outreach and Education Task Force. The task force shares its recommendations regarding different issues and questions affecting the O&P community. The first article in this series was published in the October 2018 issue of O&P Almanac.



Medicare Administrative Contractor (DME MAC) Comprehensive Error Rate Testing (CERT) Outreach and Education Task Force analyzes CERT data trends for different durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) categories. We see errors in delivery documentation across all orthotic and prosthetic types. Here, we will focus on Medicare’s requirements and documentation guidelines for delivering O&P items to Medicare beneficiaries. Any time an O&P supplier/provider— which could be a brick-and-mortar DME supplier, a certified prosthetist or orthotist office, or a physician/nonphysician practitioner office—provides/delivers an item to a Medicare beneficiary, there must be documentation showing what was provided and when it was provided. This is one of the Supplier Standards.

In case of an audit, this documentation will likely be requested by the auditing entity, and the O&P supplier will be expected to provide the proof of delivery. There are a few ways to deliver an O&P item and show proof of delivery.

Direct Delivery to a Beneficiary The first method, direct delivery to a beneficiary, means the item is provided directly to the beneficiary, who signs for it when he or she takes possession. This is the most common avenue of delivery for the O&P industry since the prosthetist/orthotist wants to ensure a correct fit and immediately alleviate any issues. The majority of the time, the Medicare beneficiary actually takes possession of the item at the O&P office when he or she comes in for a final fitting. The orthotics and prosthetics supplier must have a document (proof of delivery) that includes the following:


• Medicare beneficiary’s name • Delivery address: This is the address where the beneficiary takes possession of the item. If the beneficiary comes to the O&P supplier/provider business location, that business address must be on the proof of delivery document. • Description of the item: The description can be a narrative description (e.g., lower-limb walking boot), a Health Care Common Procedure Coding System (HCPCS) code, the long description of a HCPCS code, or a brand name/model number. • Quantity delivered: Even if one item is provided, the quantity is still a required element for proof of delivery. • Date delivered: This is the date the beneficiary takes possession of the orthotic or prosthetic item. The delivery date can be entered on the document by the beneficiary or the O&P supplier/provider representative, or it can be preprinted when the supplier/provider’s system generates and prints the document. If the beneficiary dates the document, and it is incorrect, there could be problems if the claim is audited as it will likely be denied for incorrect date of service by the auditing contractor. To avoid this denial, many suppliers have removed the “Date” cell beside the beneficiary’s signature section on the document. • Beneficiary (or designee) signature: If a beneficiary is unable to sign, he or she may have a designee sign on his or her behalf. The date delivered on the document must be the date of service on the claim billed to the DME MAC.

Delivery Utilizing a Shipping Service

The second method for proof of delivery is the utilization of a shipping or delivery service. This does not occur often in the O&P profession because the supplier/provider wants to verify the fit of an orthosis or prosthesis and ensure the item meets the needs of the Medicare beneficiary.

There are two differences between direct delivery and using a shipping service: package identifi­ cation information and evidence of delivery instead of a Medicare benefi­ciary signature.

When a shipping/delivery service is used, the proof of delivery document must include the following: • Medicare beneficiary’s name • Delivery address • Delivery service’s package identification number, supplier invoice number, or alternative method that links the supplier’s delivery documents with the delivery service’s records • Description of the items • Quantity delivered • Date delivered • Evidence of delivery. Please note the two differences between direct delivery and using a shipping service: package identification information and evidence of delivery instead of a Medicare beneficiary signature. If a supplier utilizes a shipping service or mail order, suppliers have two options for the date of service to use on the claim: 1. Suppliers may use the shipping date as the date of service billed to the Medicare program. The shipping date is defined as the date the delivery/

shipping service label is created or the date the item is retrieved by the shipping service for delivery. However, such dates should not demonstrate significant variation. 2. Suppliers may use the date of delivery as the date of service on the claim. Suppliers also may utilize a return postage-paid delivery invoice from the beneficiary or designee as proof of delivery. This type of proof of delivery document must contain the information specified above. Since there a few nuances to delivery when utilizing a shipping service, take a look at the following scenario: ABC O&P is contacted by Medicare beneficiary John Doe on December 5. John states that he is in need of two pairs of socks for his lower-limb prosthesis. ABC O&P verifies it has a valid detailed written order on file for John and asks about the need to replace the socks. John tells ABC that the socks he currently has are worn out, have a couple of holes in them, and don’t protect his residual limb very well.




ABC then asks John if he wants to come in to the facility or if he would like the socks to be shipped to him. John replies that he would prefer shipping so he doesn’t have to drive in to the city for the socks. ABC O&P processes the request and gets the socks ready to ship. ABC finds that UPS is the most efficient in terms of cost and timeliness, so a staff member prepares a UPS shipping label. When typing in the information for John’s address, ABC adds its invoice number to the “Notes” section. When the UPS label prints, ABC writes down the “1Z” UPS tracking number on its file copy of the invoice. ABC includes the invoice with the socks, and the UPS driver picks up the package that afternoon and puts it on his truck. Four days later, on December 9, ABC O&P checks the UPS website to be sure the socks were delivered in a timely manner. The tracking data shows that John Doe signed for the socks on December 8. This scenario presents valid proof of delivery using a shipping service. ABC O&P followed the necessary steps to ensure all required elements were met. ABC O&P had a document—its invoice—that referenced the shipper’s documentation, and vice versa. The O&P facility had evidence of delivery (by checking the UPS website for verification). The company could bill the date of service to Medicare as December 5 (the day the label was created and UPS took possession of the package) or December 8 (the day John Doe signed for the package). Most DMEPOS suppliers would use the December 5 date because they can input the information in their billing systems once the shipper label is created.

Delivery to a Skilled Nursing Facility on Behalf of a Beneficiary

The third method of delivery is the provision of an O&P item to a beneficiary in a skilled nursing facility. For items directly delivered by the supplier to a nursing facility or when a delivery service or mail order is used 46


of delivery is one of the

fitting or training the beneficiary in the proper use of the item. This may be done up to two days prior to the beneficiary’s anticipated discharge to his or her home. The supplier must bill the date of service on the claim as the date of discharge and shall use the “Place of Service” as 12 (home). The item must be intended for subsequent use in the beneficiary’s home. No billing may be made for the item on those days the beneficiary was receiving training or fitting in the hospital or nursing facility.

Supplier Standards and

Following the Rules

Remember that proof

that any auditing entity may ask for delivery documentation to support the O&P item billed to the DME MAC. to deliver an item to a nursing facility, the DMEPOS supplier must have the following: documentation demonstrating delivery of the item(s) to the facility by the supplier or delivery entity; and documentation from the nursing facility demonstrating receipt and/or usage of the item(s) by the beneficiary. The quantities delivered and used by the beneficiary must justify the quantity billed. The date of service billed to the Medicare program will be determined by the method of delivery. If the O&P company employee hand delivers the item to the beneficiary and the beneficiary, or a designee, signs for it, that is the date of service billed to the Medicare program. If the O&P company ships the items to the Medicare beneficiary via a shipping service, then the date of service billed to Medicare would be based on the date the label was created, the date the shipper added it to its system, or the date it was signed for by a skilled nursing facility employee.

Proof of Delivery Exception An O&P supplier may deliver O&P items to a beneficiary in a hospital or nursing facility for the purpose of

Remember that proof of delivery is one of the Supplier Standards and that any auditing entity may ask for delivery documentation to support the O&P item billed to the DME MAC. The entity auditing the claim will verify the O&P item billed to fee-for-service Medicare as well as the date of service billed on the claim. Refer to the Local Coverage Determination and related Policy Article if necessary to ensure that an item may be shipped via a shipping service because some items must have an in-person delivery—for example, diabetic shoes. Disclaimer: This article is a summary of the Standard Documentation Requirements and is accurate as of May 28, 2019. Suppliers are strongly encouraged to read the applicable Local Coverage Determination, related Policy Article, and Standard Documentation Requirements for All Claims Submitted to the DME MACs (A55426) for the most up-to-date guidance on coverage, coding, and documentation requirements. Take advantage of the opportunity to earn two CE credits today! Take the quiz by scanning the QR code or visit bit.ly/OPalmanacQuiz. Earn CE credits accepted by certifying boards:


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Serial Specialization Michael Wininger, PhD, puts his multitasking skills to use in the O&P research arena

O&P Almanac introduces individuals who have undertaken O&P-focused research projects. Here, you will get to know colleagues and healthcare professionals who have carried out studies and gathered quantitative and/ or qualitative data related to orthotics and prosthetics, and find out what it takes to become an O&P researcher.



of their lives focused on one narrow area of investigation and study. But Michael Wininger, PhD, a statistician who has conducted some important O&P research, has chosen an alternate pathway—one that he calls “serial specialization.” “Rather than a single area of focus, I am able to take on projects as they arise, deliver a product to one patient population, and then move on to the next opportunity,” Wininger says. “This kind of episodic engagement keeps me happy, with constant stimulation.” It is perhaps fitting that Wininger— who describes himself as an engineer with an interest in data science—has several significant job titles: associate professor at the University of Hartford (UHart), statistician of medicine at the U.S. Department of Veterans Affairs (VA), and clinical assistant professor at the Yale School of Public Health. Having three different appointments allows Wininger “to create research products that cut across the three main theaters in O&P: clinical practice, academic research, and career training,” he explains. Through professional collaborations and consultancies, he is able to tie in industry. “In each of these arenas, there is someone whom I consider a ‘customer’: Clinicians need definitive guidance

on how to treat patients; clinic managers want data-driven platforms for decision making in order to maintain competitive advantage; and the students need to know that they have a faculty member who is sharpening the cutting edge,” he says. “Working in these different ecosystems allows me the ability to not only design products that serve a broader good, but to take creative paths to solution. I feel that there is just as much merit to innovating the methodology as there is in producing an innovative result.”

Adventures in Force Myography

Wininger got his “start” in O&P while completing undergraduate degrees in physics and math at the University of Connecticut. “UConn immersed me in the most rigorous training in both pure and applied analytical skills, which turned out to be the pivotal assets and the foundation that supported my transition into biomedical engineering,” he says. Wininger started to see opportunity in engineering and prosthetics while an undergraduate student, when he learned about the work of William (Bill) Craelius, PhD, at Rutgers University. “Bill had written a seminal paper about prosthetic technology for a major scientific journal and was developing a technology that would ultimately become ‘force myography,’ a groundbreaking

PHOTO: Michael Wininger, PhD




Michael Wininger, PhD, in a statistics instructional video

PHOTO: Michael Wininger, PhD

noninvasive sensing technology for prosthetic control,” explains Wininger. Force myography is an alternative technique that involves monitoring the outward force, or pressure, at the surface of the limb as muscles expand and contract, as a means to characterize the state of the underlying musculotendinous complex. Wininger visited Rutgers, and Craelius became his mentor. And just as importantly, says Wininger, he found Rutgers’ Biomedical Engineering Department to be a highly fertile environment, packed with cell biologists, device experts, microscopists and imagers, clinicians, informaticists, and many types of engineers. “At Rutgers, I saw that O&P was more than a clinical subspecialty in the allied health world and was rising with the tide of highly integrative biomedicine.” Wininger ended up at Rutgers to pursue his PhD in biomedical engineering. The first paper he ever wrote as a young graduate student introduced force myography in its modern state; that paper was published in 2009 in the Journal of Rehabilitation Research and Development. “As our work in biomedical devices progressed, my teammates were showing brilliance in

the hardware design, which drove me to develop expertise in signal processing, computer programming, and, ultimately, biostatistics,” Wininger says. “This evolution has led me to where I am now: a fanatic for analytics and study design.”

Ongoing Investigations

Today, Wininger’s role as faculty in the Department of Rehabilitation Sciences at UHart allows him to continue to wear many hats—as a teacher, investigator, and statistician. There, he continues to conduct investigations into advances in rehabilitation robotics and force myography, which draws in UHart students with an academic focus in O&P and biomedical engineering. He also is involved in several studies at the VA and Yale. His research at those institutions has broad scope and includes trials in heart failure, rehabilitation medicine, and surgery. “I am highly application oriented, but [I] enjoy writing methodological papers every chance I get,” Wininger says. By cultivating these parallel research programs in both bench science and public health statistics, he is laying the foundation for a transformative

platform in clinical science research and development. “I’m very proud of my association with force myography and continue this line of research to this day,” says Wininger. But he admits his “deepest drive” is to design clinical trials in O&P. “As a statistician with experience in clinical trials, I am compelled to gather my colleagues in a team effort to identify priority research targets, formulate the proper research questions, and provide definitive answers.” Wininger works obsessively to ensure that his efforts will manifest betterment for the O&P population. Every time he writes a paper, he assesses the benefit to patients while providing data that will be useful to payors. “My goals are to deliver a scrutable, reproducible hypothesis test with relevance and consequence to the patient population, and to provide a framework of study design and analysis that serves as a model of best practice,” he explains. “Payors should be able to take away specific wisdoms regarding the tested treatments, and my colleagues should be able to take away empirical approaches that will serve them well as they design their own studies.” O&P ALMANAC | JULY 2019



“There are tens of thousands of registered trials in cancer, heart failure, and mental health, but only a handful in prosthetics and orthotics." —MICHAEL WININGER, PhD

Michael Wininger, PhD, speaking at the AOPA 2017 World Congress

Sharing His Interests



the question,” he explains. “Some folks will be comfortable generating questions; others will prefer to design the tools to answer the question. Whichever mentality suits you, I say: Embrace it and practice! There is great need for both question-posers and solution-finders out there, so find your inner voice and get involved.” When he gets a break from his many professional roles, Wininger stays busy by spending time with his family, which includes his wife and two children. “My favorite activities

are co-parenting and being a kid again with my son and daughter,” he says. And while he is constantly on the lookout for the latest innovations in science and data analytics, he confesses to being a little behind the curve in adoption of other technologies: “I still own a flip phone!” he admits. Despite his reliance on older cell phone technology, Wininger is ready to embrace the future of O&P—and willing to do his part to advance the profession through both teaching and clinical investigations.

Notable Works Michael Wininger, PhD, has been involved in the publication of 45 peer-reviewed journal articles. Some of his most relevant works include the following: • Curcio, B.C., Cirillo, N.V., Wininger, M. “Force Myography Across Socket Material.” Journal of Prosthetics and Orthotics, In Press. (Accepted for publication Nov. 16, 2018.) • Wininger, M., Kim, N.H., Craelius, W. “Pressure Signature of Forearm as Predictor of Grip Force.” Journal of Rehabilitation Research & Development 2008; 45(6): 883-892. • Wininger, M. “Formulating Clinical Trials in Prosthetics and Orthotics and Allied Health Fields.” Journal of Prosthetics and Orthotics 2017; 29(1): 2-6. • Dornfeld, C., Swanston, M., Cassella, J., Beasley, C., Green, J., Moshayev, Y., Wininger, M. “Is the Prosthetic Homologue Necessary for Embodiment?” Frontiers in Neurorobotics 2016; 10(21).

PHOTO: Michael Wininger, PhD

One of Wininger’s side goals is to spark an interest in O&P research among students as well as clinicians. “There is an urgent need to facilitate clinical trials in O&P,” he says. “There are tens of thousands of registered trials in cancer, heart failure, and mental health, but only a handful in prosthetics and orthotics. “Without a doubt, we need to focus our energies on establishing a culture and an infrastructure that supports clinical trials, with attention paid to implementation science—translating study outcomes into clinical practice and healthcare policy.” Wininger takes seriously his role as an educator of future researchers. “All of my students become an expert in their topic of interest, and also expert in study design and analysis,” he explains. “Interests will change over time, but the rudiments of hypothesis formulation and testing are permanent. Regardless of what career path my students choose, they will carry with them the ability to think critically, test objectively, and interpret and report their data appropriately.” Over the past several years, he has mentored more than a dozen students to their first peer-reviewed journal publications. To those who are interested in but reluctant to try research, Wininger says there is a place for everyone. “Research is a two-step process: Identify your research question, and then answer

Who is an innovator? Who is held to the highest O&P standards? Who is committed to life-long learning? I AM. I am a big part of great possibilities.

I AM ABC. Visit ABCop.org today to find out what ABC can do for you. 703.836.7114

Vegas Is About

Risk Taking Learn to mitigate your business risks, register for the Mastering Medicare: Essential Coding and Billing Techniques in Las Vegas, November 4-5. But don’t, take our word for it. Attendees from the last seminar said:

Great takeaways and clarifications of topics that we are actively working on in the office. I wish all staff could attend!

This was my third time at this course.

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For more than 20 years, our faculty have helped thousands of attendees get claims paid, survive audits, collect interest from Medicare, file successful appeals and code miscellaneous items.

Speakers did a great job. Thoroughly covered topics, were engaging and entertaining.

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Each Seminar is updated based on the latest developments, feedback from previous attendees, and needs of the profession. It is two days full of valuable instruction on topics O&P providers face daily, like prior authorization, competitive bidding, Medicare documentation requirements, and new codes. Additionally, 14 CE credits can be earned.

Attendees are responsible for making their own hotel reservations. Book by October 7 for the $135/ night rate by calling 800/374-9000 and asking for the AOPA Coding and Billing Seminar rate.

NOVEMBER 4-5, 2019

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For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. .





Implant Experts Swedish company facilitates osseointegration



PHOTOS: Integrum

performed groundbreaking surgery to implant a transfemoral osseointegrated prosthesis in an amputee. Eight years later, one of those surgeons, Per-Ingvar Brånemark, along with Rickard Brånemark, MD, PhD, founded Integrum in Gothenburg, Sweden. Integrum’s OPRA™ Implant System, which stands for Osseoanchored Prostheses for the Rehabilitation of Amputees, was approved by the European Union in 1999 and soon put to use in the United Kingdom, Australia, France, and Spain. Osseointegration involves implanting a titanium fixture into the bone of a residual limb. A second, modular piece, called the abutment, is connected to the fixture anchored in the bone. A connection device called the Axor™ connects to the abutment, which in turn connects to the prosthesis. The benefits are significant, says Kurt Collier, CP, vice president of prosthetics at Integrum Inc., the U.S. division of the company, based in San Francisco. It is designed to be more stable than a traditional attachment and to eliminate the discomfort of a socket, according to Collier. The OPRA™ Implant System’s Axor™ comes with several safety features designed to keep the fixture and the bone healthy. Collier notes that the Axor™ will release if the patient creates excessive rotary force. “In addition, if a patient falls to the knees and the force in falling is excessive, another mechanism in the Axor™ will release like a ski binding,” he says. If force is high enough, the abutment

Integrum’s Neuromotus system is designed to help eliminate phantom limb pain.

The OPRA™ Implant System

COMPANY: Integrum OWNER: Publicly traded on Nasdaq First North, Stockholm, Sweden LOCATIONS: Headquartered in Sweden, with U.S. subsidiary in San Francisco, California HISTORY: 21 years

will bend before it can cause damage to the bone, and the modularity of design means it can be easily replaced, Collier says. The United States has been slower to approve osseointegration surgery, but in 2015, the U.S. Food and Drug Administration (FDA) awarded a humanitarian device exemption (HDE) to the OPRA™ Implant System for transfemoral implants. Collier stresses that osseointegration is not suitable for every amputee. Eligible individuals are amputees limited with a traditional socketed prosthesis due to, for instance, a short residual limb or excessive scarring, including skin grafts or invaginated scars. Furthermore, Collier notes, the fixture may fail to integrate with the bone in up to 10 percent of patients, so patient screening is an important aspect of the treatment protocol. Collier says many patient report dramatic results. “The feel of an osseointegrated limb is so much more natural, and control is more intuitive.”

Integrum uses the OPRA™ Implant System outside of the United States for upper extremities, at the transradial and transhumeral levels and for the thumb and fingers. “We have also provided it at the transtibial level, but we want to continue research at this level,” he says. Integrum also is exploring the integration of nerve and electronic systems. It developed Neuromotus, a noninvasive system designed to alleviate phantom limb pain. Electrodes capture neuromuscular impulses and create a phantom limb on a computer screen. As patients visualize making a movement— flexing the elbow, opening the hand—the digital image will move. While similar to mirror therapy, Neuromotus requires no intact limb, and it is suitable for patients with residual muscle activity. Another research avenue is a nerve-controlled prosthetic limb. Integrum is developing both upper- and lower-limb solutions that can be wired to receive brain impulses, thus enabling greater prosthetic control. “We also created a nerve band clamp, a wrist cuff, that is surgically placed right around the nerve. When the brain sends an impulse to close the hand, the signal is received through the wires running through osseointegrated abutment to a microprocessor in the prosthesis,” explains Collier. When sensors in the fingertips of the prosthesis are stimulated, the patient will experience the sensation of touching something. Integrum is still a small company and only went public 2017, according to Collier. But with the FDA’s HDE designation, osseointegration may soon become more common in the United States. And that could mean good things for the company—as well as thousands of amputees. Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net. O&P ALMANAC | JULY 2019



2019 AOPA National Assembly and Combined California Orthotic & Prosthetic Association (COPA) Meeting SEPTEMBER 25-28, 2019 | SAN DIEGO CONVENTION CENTER



The National Assembly is the country’s oldest and largest meeting for the orthotic, prosthetic, and pedorthic professions in North America. Grow your customer base and introduce new products at this premier event.

WHAT YOU RECEIVE • Two exhibitor full conference badges (per

WHY EXHIBIT? • Build your customer base and increase sales by

meeting with Facility Owners and decision-making practitioners.

• Experience face-to-face time with existing customers to answer questions and build new relationships.

• Enjoy sponsored networking opportunities, including an

10x10 exhibit space) which includes admission to all education sessions, CE credits, meeting materials, welcome reception, and lunch tickets.

• Additional discounted full conference badges

once complimentary exhibitor badges are used.

• Ability to receive CE credits with your full conference registration badge.

• FREE breakfast and lunch during show hours conveniently located inside the exhibit hall.

opening welcome reception in the exhibit hall.

• Increase your exposure through a wide variety of advertising & sponsorship opportunities

• Speak to AOPA reimbursement experts who can

answer all your O&P coding, reimbursement and compliance questions.

• Much more! FOLLOW US @AmericanOandP

Want to take advantage of an exhibit and/or sponsorship opportunity? Contact Kelly O’Neill at 571/431-0852 or kelly.oneill@AOPAnet.org.



Long Island O&P and North Shore Orthotics-Prosthetics

The Human—and Animal—Connection New York clinician treats patients of many ages—and species



career working for an O&P facility in New York, Marc Werner, CPO, launched his own company, Long Island Orthotics & Prosthetics, in West Babylon, New York, in 2009. “Starting a company from scratch was kind of a trial by fire,” he recalls. “Finding a space, getting permits, doing a buildout, getting Medicare numbers and billing information—it was an enlightening experience! There’s no manual that explains the steps and timelines, so we just dove in.” Fortunately, Werner found friendly competitors who were happy to help answer questions.

Marc Werner, CPO, opened Long Island Orthotics & Prosthetics 10 years ago. facility. He employs two techni-

FACILITY: cians: Sean Rapp, who does most of Long Island Orthotics the prosthetic work at Long Island, & Prosthetics and Carlos Rivera, who focuses on OWNER: Marc Werner, CPO LOCATION: West Babylon, New York

Marc Werner, CPO

Karen Werner

PHOTOS: Long Island O&P and North Shore Orthotics-Prosthetics

Today, Werner heads two facilities, Long Island O&P as well as North Shore Orthotics-Prosthetics, in Port Jefferson Station, New York, which was purchased by his wife about four years ago. Werner’s goal is to bring the two companies under one roof, and he’s considering the purchase of a new facility with about 6,500 square feet. Whether or not the two companies merge, Werner will share staff and clinicians between them. Currently, Werner is joined by Monica Rogers, CO, who takes care of pediatric orthotic patients primarily at the North Shore office, and Trina Gordon, CP, who works with Werner in the Long Island

HISTORY: 10 Years FACILITY: North Shore Orthotics-Prosthetics OWNER: Karen Werner LOCATION: Port Jefferson Station, New York HISTORY: 30 years; four under Werner

orthotics at North Shore. Werner’s wife, Karen, handles billing, human resources, and other administrative duties at North Shore. Between the two facilities, Werner offers the full gamut of prosthetic and orthotic devices, all fabricated in-house. He sees a wide range of patients—from newborns, to athletes, to seniors. He also treats animals, often in collaboration with local veterinarians. “I’ve made prosthetic legs and [anterior cruciate ligament] braces for dogs, and I have recently worked with a baby llama. He was born with his legs mispositioned in utero, so they were bowed. I made him braces to straighten out his legs,” he says. Werner manages to fit several additional activities into his schedule. He is on the board of directors of Amp 1 Basketball, a team of amputees that plays full-court, stand-up basketball all over the United States. He first


became involved through two of his patients and has been active in the organization for several years. He also participates in grant studies involving amputees, working with Eric Lamberg, PT, EdD, CPed, director of physical therapy at Stony Brook University. And Werner was just voted Instructor of the Year for his Clinical Education Concepts courses, through which he provides continuing education courses for physical therapists (PTs) and occupational therapists (OTs) at about 20 different facilities. He teaches additional courses to physiatrists, PTs, and OTs at local hospitals and colleges. Werner’s connections with area OTs and PTs are effective in marketing his facilities; he also takes full advantage of social media. Werner’s son, Charley, recently graduated with a degree in graphic design, and he maintains the facility’s website and social media presence on Facebook, Instagram, and Twitter. Werner’s elder daughter, Celia, has a degree in television and video film production; she produces videos highlighting patient stories, interviews, and newsworthy events. Werner’s youngest, Chelsea, who has been a patient at the Long Island location many times in her athletic career, is currently not part of the family business but is pursuing a master’s degree in advanced medical imaging. The process to reach this point in his career has been demanding, but Werner thoroughly enjoys the results. “I have the flexibility to do what I want. I can teach, work with patients—including animals—and spend time with my family at home and work,” he says. “We try to treat everyone like family, and that means taking the time to do it right.” Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net. O&P ALMANAC | JULY 2019




Register Now for the 2019 AOPA National Assembly The 2019 AOPA National Assembly has it all: • Best-in-business education and advanced clinical programming • The largest O&P exhibit hall in the United States

• • • •

Networking with the most influential people in the profession Must-attend events An opportunity to earn more than 40 CE credits The legendary weather, beautiful beaches, and friendly, laid-back vibe of San Diego.

Learn more and register—visit www.AOPAnet.org. Together we will drive the waves of change. AOPA is proud to partner with the California Orthotics & Prosthetics Association to bring you the 2019 National Assembly.



Are You Ready for the Worst? Contingency Planning

AOPAversity Webinars During the one-hour monthly webinars, AOPA experts provide the most up-to-date information on a specific topic. Webinars are held the second Wednesday of each month at 1 p.m. EST. One registration is all it takes to provide the most reliable business information and CE credits for your entire staff. If you’ve missed a webinar, AOPA will send you a recording of the webinar and quiz for CE credits, so you can still take advantage of the series discount and the valuable learning opportunities. Sign Up for the 2019 Half-Year Series & Save! Registration Fee

AOPA Members Nonmembers

Price Per Seminar

$99.00* $199.00*

Price for Half-Year

$495.00 $995.00

* Includes an unlimited number of participants per telephone line. AOPA members may use code “member” when registering for the $99 price.

Earn 1.5 Business CEs each by returning the provided quiz within 30 days and scoring at least 80 percent. All webinars begin at 1 p.m. EST. Webinar registration fees are nonrefundable. AOPA can provide the webinar recording if registrants cannot make the scheduled webinar.



Is your facility prepared for the next natural disaster? Take steps now to minimize disruptions in the event of fire, flood, hurricanes, and other unexpected events. Experts will share tips and recommendations for creating a contingency plan, testing that plan, and carrying out that plan should a disaster occur. Plus, make sure you have all of the necessary insurance coverages in place.



Veteran Affairs Updates: Contracting, Special Reports, and Other News Receive an update on the current and proposed rules at the U.S. Department of Veterans Affairs (VA) that may have an impact on the O&P field: • The 2017 proposed rule for Prosthetic & Rehabilitative Items & Services • The VA Office of Inspector General report on miscellaneous codes • VA contracts and contracting • And more.


Welcome New AOPA Members



American Orthotic & Prosthetic Association (AOPA) are pleased to present these applicants for membership. Each company will become an official member of AOPA if, within 30 days of publication, no objections are made regarding the company’s ability to meet the qualifications and requirements of membership. At the end of each new facility listing is the name of the certified or state-licensed practitioner who qualifies that patient-care facility for membership according to AOPA’s bylaws. Affiliate members do not require a certified or statelicensed practitioner to be eligible for membership. At the end of each new supplier member listing is the supplier level associated with that company. Supplier levels are based on annual gross sales volume.

Carolina Amputee & Orthotics Inc. 1921 Tate Blvd., SE Hickory, NC 28602 828/441-2011 Member Type: Patient-Care Facility

VitalFit SR 8860 Center Drive, Ste. 300 La Mesa, CA 91942 888/452-7948 Member Type: Supplier

Mark Goldberg Prosthetic & Orthotic Labs 59-05 69th Street Maspeth, NY 11378 631/689-6606 Member Type: Affiliate

Membership has its benefits:



Learn more at www.AOPAnet.org/join


Advertisers Index Company

Page Phone



American Board for Certification in Orthotics, Prosthetics, and Pedorthics

51 703/836-7114



17 800/356-3668


Apis Footwear Company




Cailor Fleming








Fabtech Systems LLC





35 512/777-3814




1 800/301-8275


www.hanger.com www.hersco.com

Naked Prosthetics




Nebraska Spine + Pain Center




Össur Americas Inc.





C4 800/328-4058






TRS Prosthetics



www.trsprosthetics.com O&P ALMANAC | JULY 2019




Opportunities for O&P Professionals

Orthotist Position—Nebraska Spine + Pain Center

Job location key: - Northeast - Mid-Atlantic - Southeast - North Central - Inter-Mountain - Pacific

Hire employees and promote services by placing your classified ad in the O&P Almanac. When placing a blind ad, the advertiser may request that responses be sent to an ad number, to be assigned by AOPA. Responses to O&P box numbers are forwarded free of charge. Include your company logo with your listing free of charge. Deadline: Advertisements and payments need to be received one month prior to publication date in order to be printed in the magazine. Ads can be posted and updated any time online on the O&P Job Board at jobs.AOPAnet.org. No orders or cancellations are taken by phone. Submit ads by email to ymazur@AOPAnet.org or fax to 571/431-0899, along with VISA or MasterCard number, cardholder name, and expiration date. Mail typed advertisements and checks in U.S. currency (made out to AOPA) to P.O. Box 34711, Alexandria, VA 22334-0711. Note: AOPA reserves the right to edit Job listings for space and style considerations. O&P Almanac Careers Rates Color Ad Special 1/4 Page ad 1/2 Page ad

Member $482 $634

Listing Word Count 50 or less 51-75 76-120 121+

Member Nonmember $140 $280 $190 $380 $260 $520 $2.25 per word $5 per word

Nonmember $678 $830

ONLINE: O&P Job Board Rates Visit the only online job board in the industry at jobs.AOPAnet.org. Job Board

Member Nonmember $85 $150

For more opportunities, visit: http://jobs.aopanet.org.


A large number of O&P Almanac readers view the digital issue— If you’re missing out, apply for an eSubscription by subscribing at bit.ly/AlmanacEsubscribe, or visit issuu.com/americanoandp to view your trusted source of everything O&P.




Omaha, Nebraska Available position for orthotist in Omaha, Nebraska, at Nebraska Spine + Pain Center, the most comprehensive spine and pain care center in the midwest region. Work as an integral part of a dynamic team of experienced physician and mid-level providers while providing an excellent patient experience. Position requires some flexibility and could be full-time or part-time in nature. Position responsibilities: • Fit, test, and adjust devices on spine patients. • Instruct patients on how to use and care for their medical devices. • Communicate with physicians to determine most appropriate device for each unique individual. • Measure patients in order to design and fit medical device appropriately. • Fabricate custom braces for spinal patients as needed. • Document care in patient medical records and bill for devices. • Repair or update medical devices as needed. • Manage inventory of off-the-shelf braces and supplies. • Deliver braces to patients at hospital following surgeries as needed. Job qualifications: • Experience required in all areas of bracing including: custom design, fabrication, and fitting of medical supportive devices for spinal patients with a variety of conditions. Must also be comfortable with off-the-shelf devices. • Results oriented, self-motivator with proven record of accomplishment. • Commitment to providing excellent customer service for both patients and physicians. • Ability to work as an integral part of professional team. • Excellent interpersonal and communication skills with a variety of audiences required. • Ability to supervise and train ancillary individuals as needed. Requirements: • Master’s degree in Orthotics and Prosthetics. • Minimum of five years’ experience. • Experience in custom spinal orthosis fabrication.

Sue Carlson, Director of Clinical Services Phone: 402/496-5535 Email: scarlson@nebraskaspineandpain.com

CAREERS Northeast

CO/CPO and/or Technician

Long Island and Queens, New York Wanted: CO/CPO and/or technician for busy Long Island and Queens practice. Excellent pay and comprehensive benefits package. Must be professional, knowledgeable, and caring. Technician must have experience pouring and modifying casts. Apply by email to : Mark Goldberg Prosthetic & Orthotic Labs Email: careers@mgpolabs.com

WANTED! A few good businesses for sale. Lloyds Capital Inc. has sold over 150 practices in the last 26 years. If you want to sell your business or just need to know its worth, please contact me in confidence. Barry Smith Telephone: (O) 323/722-4880 • (C) 213/379-2397 Email: loyds@ix.netcom.com




Feature your product or service in Marketplace. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net. Visit bit.ly/almanac19 for advertising options.

ALPS Anterior Posterior Tapered Liner ALPS AP Tapered Liner is gradually tapered from the anterior to the posterior to provide superior comfort. This liner is available in a pin-and-lock system or suction suspension. The AP Tapered Liner features our black high-performance fabric with gel to assist in reducing bunching in the popliteal region. Call us or visit www.easyliner.com for more details.


Sutti Bounders Store and Return Energy —Mimicking Normal Muscle Function New “Sutti Bounders” modular pediatric dynamic elastomers are a patent-pending elastomer technology that offer two progressive solutions. Sutti No tools for on the fly adjustments Bounders store and return by healthcare providers energy—mimicking normal muscle function to produce both eccentric and concentric contractions and, if needed, a groundreaction force. Smart and simple modular design, standardized sizes, and three levels of performance to choose from add up to an easy-to-use expandable dynamic system to treat your pediatric and young adult patient base. For more information, visit www.fabtechsystems.com/ bounders or call 800/322-8234.

LEAP Balance Brace

Apis custom program offers practitioners best options and services for patient compliance. All products are covered under risk-free guaranteed fit promise. We stand firmly behind our words. Call us at 1-888/937-2747.

The Original Pre-Flexed Suspension Sleeve ESP created the Flexi family of suspension sleeves as a comfortable, durable, and cost-effective alternative to traditional suspension sleeves. Pre-flexed at 43 degrees for maximum comfort and natural unrestricted movement. For more information, call ESP LLC at 888/932-7377 or visit www.wearesp.com.



Hersco’s Lower-Extremity Ankle Protection (LEAP) brace is designed to aid stability and proprioception for patients at risk for trips and falls. The LEAP is a short, semirigid ankle-foot orthosis that is functionally balanced to support the foot and ankle complex. It is fully lined with a lightweight and cushioning Velcloth interface, and is easily secured and removed with two Velcro straps and a padded tongue. For more information, call 800/301-8275 or visit www.hersco.com.

Naked Prosthetics Naked Prosthetics designs and manufactures high-quality prosthetic devices specifically for finger loss. Our mission is to assist people with digit amputation(s) and positively impact their lives with fully articulating, custom finger prostheses. Our product aims to restore the ability to perform most tasks, supporting job retention and an active lifestyle. Our customers have lost fingers to power tools, equipment malfunctions, injury in the line of military service, random accidents, and infections; in some cases, multiple digits have been lost. NP provides a viable functional prosthesis, as opposed to a passive cosmetic solution. Our design mimics finger motion and utilizes the remainder of an amputee’s digit to power the device. For more information, visit www.npdevices.com.


Discover PROTEOR USA Proprio Foot® debuted in 2006 with a simple goal: to reduce trips and falls. This latest-generation microprocessor ankle, built upon a Pro-Flex® LP foot module, provides 44 percent more toe-off power—taking us one step closer to our goal. Visit ossur.com/proprio-foot to learn more.

From Land to Water With Ottobock’s Aqualine Orthosis System The Aqualine AFO/KAFO is a waterproof orthosis system for the shower, pool, beach, and more. • Durable, waterproof, and corrosion-resistant to chlorine, salt, and soapy water • Lightweight knee and ankle joints suitable for both thermoplastic and prepreg orthoses • Easy to clean, easy to dry, and fully serviceable components • Ask about our current Aqualine promotion. For more information, call 800-328-4058 or visit professionals.ottobockus.com.

Introducing 1C50 Taleo® From Ottobock Ready for everyday life. The carbon-fiber Taleo foot is the newest foot in our portfolio. Designed for your active K3 patients who navigate varied indoor and outdoor environments and place a high value on effortless walking and the ability to go wherever life takes them. • Smooth rollover for effortless walking • Delivers performance suited to each step • Supports dynamic movement across varying terrain conditions.

Delivering an extensive, progressive product line that includes everything today’s active amputees need to live the life they love. Offering an innovative portfolio that includes everything from the virtually indestructible RUSH Foot collection to the world’s first microprocessor-controlled hydraulic four-bar knee with both stance and swing functionality, the ALLUX. The EASY RIDE, multiuse extreme sports knee, to the KEASY, renowned prefabricated cones. The K2 GERY foot to the flexible, all-terrain, DynaTrek foot. Discover the exciting PROTEOR USA product line today! A whole new look. A whole new vibe. A whole new world. #HumanFirst. Visit us at proteorUSA.com.

JAWS VO PRENENSOR JAWS is a high-performance, voluntary opening, prosthetic terminal device operated with or without a cable. JAWS's gripping force is easily user adjustable, utilizing proven “vector” technology. JAWS has a prehensile, not a hook, configuration for better control of ATVs, motorcycles, snowmobiles, personal watercraft, and lawn mowers, as well as working tools, domestic, garden, and yard tool handles. It snaps on and off objects with variable gripping forces exceeding 50 pounds. Additionally, JAWS features an integral, friction adjustable, radial-ulnar pivot. Preview models of JAWS at the AOPA conference in September. TRS is BODY POWER. For more information, 800/279-1865 or visit trsprosthetics.com.

For more information, visit www.professionals.ottobockus.com or talk to your sales representative.




APPLY ANYTIME! BOC Certification. Apply anytime and www.bocusa.org test when ready for the orthotic fitter, mastectomy fitter, and DME specialist certifications. To learn more about BOC’s nationally recognized, in-demand credentials and to apply today, visit www.bocusa.org.

August 1

ABC: Application Deadline for ABC/OPERF Resident Travel Award. Four residents will be selected to present their Directed Study Research project at the 2020 Academy Annual Meeting and receive $2,500 plus complimentary meeting registration. For more info or to apply, go to operf.org.

August 5–10

Cascade Dafo Institute

Eight free ABC-approved online continuing education courses for pediatric practitioners. Take anytime, anywhere, and earn up to 11.75 CE credits. Visit cascadedafo.com or call 800/848-7332.

ABC: Written and Written Simulation Certification Exams. ABC certification exams will be administered for orthotists, prosthetists, pedorthists, orthotic fitters, mastectomy fitters, therapeutic shoe fitters, orthotic and prosthetic assistants, and technicians in 350 locations nationwide. Contact 703/836-7114, email certification@abcop.org, or visit ABCop.org/certification.

August 14

Are You Ready for the Worst? Contingency Planning. Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR


August 23–24

July 10

Target, Probe, Educate—Get To Know the Program & What the Results Are Telling You. Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR

July 11–13

State Association Meeting: Alabama Prosthetic & Orthotic Association. Embassy Suites Birmingham/Hoover, Birmingham, AL. For more information, email info@ alabamapoa.org or visit www.alabamapoa.org.

July 12–13

Primefare East Regional Scientific Symposium. Renaissance Hotel and Convention Center, Downtown Nashville. For more information, visit www.primecareop. com, call 888/388-5243, or email Cathie Pruitt at primecarepruitt@ gmail.com or Jane Edwards at jledwards88@att.net.

August 1

ABC: Application Deadline for October Certification Exams. Applications must be received by August 1 for individuals seeking to take the October Written and Written Simulation certification exams. Contact 703/836-7114, email certification@abcop.org, or visit ABCop.org/certification.



ABC: Orthotic Clinical Patient Management (CPM) Exam. ABC Testing Center, Tampa, FL. Contact 703/836-7114, email certification@ABCop.org, or visit ABCop.org/ certification.

August 23–24

Texas Chapter of the American Academy of Orthotists and Prosthetists: Annual Meeting. Baylor College of Medicine McNair Campus in Houston. Contact Ben Guenther at 903/884-6681 or visit www.txaaop.org.

September 1

ABC: Practitioner Residency Completion Deadline for October Exams. All practitioner candidates have an additional 30 days after the application deadline to complete their residency. Contact 703/836-7114, email certification@abcop.org, or visit ABCop.org/certification.

September 6–7

ABC: Prosthetic Clinical Patient Management (CPM) Exam. ABC Testing Center, Tampa, FL. Contact 703/8367114, email certification@abcop.org, or visit ABCop.org/certification.

September 11

Veterans Affairs Updates: Contracting, Special Reports, and Other News. Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR


September 12–14

State Association Meeting: Midwest Chapter AAOP. Grand Geneva Resort & Spa, Lake Geneva, WI. For more information, email mwcaaop@gmail.com or visit www.mwcaaop.org.

October 19

POMAC (Prosthetic and Orthotic Management Associates Corporation) Fall Continuing Education Seminar. Aloft Hotel New York LaGuardia Airport, 100-15 Ditmars Blvd., East Elmhurst, NY 11369. For more information, contact Drew Shreter at 800/946-9170, ext. 101, or email dshreter@pomac.com.

September 25–28

AOPA National Assembly. San Diego Convention Center. For general inquiries, contact Ryan Gleeson at 571/431-0836 or rgleeson@AOPAnet.org, or visit www.AOPAnet.org.

November 3–9

Healthcare Compliance & Ethics Week. AOPA is celebrating Healthcare Compliance & Ethics Week and is providing resources to help members celebrate. Learn more at bit.ly/aopaethics.

October 1

ABC: Application Deadline for December Certification Exams. Applications must be received by October 1 for individuals seeking to take the December Written and Written Simulation certification exams. Contact 703/836-7114, email certification@ABCop.org, or visit ABCop.org/certification.

October 1

ABC: Application Deadline for ABC/OPERF Student Award for Academic Achievement. Ten exceptional students will be selected to win $1,000 to cover educational expenses. For more info or to apply, go to operf.org.

ABC: Written and Written Simulation Certification Exams. ABC certification exams will be administered for orthotists, prosthetists, pedorthists, orthotic fitters, mastectomy fitters, therapeutic shoe fitters, orthotic and prosthetic assistants, and technicians in 350 locations nationwide. Contact 703/836-7114, email certification@ABCop.org, or visit ABCop.org/certification.

Performance Reviews: How Is Your Staff Doing? Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR

Calendar Rates CE For information on continuing education credits, contact the sponsor. Questions? Email ymazur@AOPAnet.org. CREDITS

Coding & Billing Seminar. Las Vegas. Book your hotel by October 7 for the $135/night rate. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org or register online at bit.ly/2019billing. SEMINAR

November 6–8

New Jersey AAOP. Harrah’s Resort Atlantic City. For general inquiries, contact Brooke Artesi , CPO, LPO, at 973/696-8100, or brooke@sunshinepando.com, or www.NJAAOP.com.

November 13

October 7–12

October 9

November 4–5

The Holiday Season—How To Provide Compliant Gifts. Register online at bit.ly/ 2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR

December 11

New Codes for 2020, Other Updates, and Yearly Roundup. Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR

Let us share your next event! Phone numbers, email addresses, and websites are counted as single words. Refer to www.AOPAnet.org for content deadlines. Send announcement and payment to: O&P Almanac, Calendar, P.O. Box 34711, Alexandria, VA 22334-0711, fax 571/431-0899, or email ymazur@AOPAnet.org along with VISA or MasterCard number, the name on the card, and expiration date. Make checks payable in U.S. currency to AOPA. Note: AOPA reserves the right to edit calendar listings for space and style considerations.




25 or less




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Time for a New Device? Medicare rules for replacing orthoses and prostheses

AOPA receives hundreds Q of queries from readers and members who have questions about some aspect of the O&P profession. Each month, we’ll share several of these questions and answers from AOPA’s expert staff with readers. If you would like to submit a question to AOPA for possible inclusion in the department, email Editor Josephine Rossi at jrossi@contentcommunicators.com.

What is the reasonable useful lifetime for orthotics and prosthetics?


The Medicare manuals state that the reasonable useful lifetime (RUL) for items is determined through program instructions, e.g., Medicare policies or regulations. In the absence of these regulations or policies, the RUL is to be set at five years. Thus, most O&P items will have a RUL of five years. There are some exemptions, however. For knee orthoses, for example, policy has set RUL between one and three years, depending on the style of brace. Another example is prostheses; these are exempt from the five-year RUL based on regulations—specifically, he Benefits Improvement and Protection Act of 2000.



When are replacement orthoses covered by Medicare?

Medicare will cover a replacement orthosis during its RUL under a few very select circumstances: • The original orthosis was lost or stolen. • The original item was irreparably damaged, and the damage was not caused by normal wear and tear. • There was a change in the patient’s condition.


In most instances when providing a replacement item during the RUL, your claim may be denied for “same or 64


similar.” In this case, you must appeal the denial and show that one of the three exemptions have been met. If a patient asks that I not bill his or her insurance, but rather bill the patient directly, must I comply with the request?


The easy answer is yes. Under the Health Insurance Portability and Accountability Act, if an individual has paid for a service out of pocket, in full, and the individual requests a nondisclosure to his or her health plan, you must accommodate the request. In previous years, you were not obligated to follow the patient’s request. However, now you are obligated—especially when the patient is making a payment directly to you.


If we are nonparticipating providers with Medicare and we are not accepting assignment on a claim, must we still obtain all of the required documentation before we can submit a claim for payment?


Yes, you are still required to adhere to all Medicare policies and procedures, and this includes ensuring you have the proper documentation to support medical necessity. The choice of being a participating or nonparticipating provider and accepting or not accepting assignment only relates to how you bill the patient and how much you may collect from the patient.



Experience all the AOPA National Assembly has to offer while visiting San Diego.


Driving the Waves of Change


Join AOPA this fall in San Diego, known for incredible panoramic views. Located in the downtown Marina district, the San Diego Convention Center has many top attractions within walking distance.


SOUTHERN CALIFORNIA San Diego’s unbeatable location makes it the perfect gateway providing you with outstanding opportunities for pre- and post-conference travel.


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Profile for AOPA

July 2019 O&P Almanac  

American Orthotic & Prosthetic Association (AOPA) - July 2019 Issue - O&P Almanac

July 2019 O&P Almanac  

American Orthotic & Prosthetic Association (AOPA) - July 2019 Issue - O&P Almanac