September 2019 O&P Almanac

Page 1



The Magazine for the Orthotics & Prosthetics Profession

S E P T E M B E R 2019

How To Bill for Returned or Refused Items P.20

O&P Students Master the Latest Technologies P.40

Research Informing Prosthesis Design and Prescription P.54

‘Open’ E! QU IZ M EARN









This Just In: Reducing Providers’ Administrative Burdens P.26




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30 | ‘Open’ Innovation


Forward-thinking O&P researchers are shaking up the traditional R&D process, taking a collaborative approach to advancing the profession. Find out how one team designed a smart robotic prosthetic leg, posted the design online, and invited researchers to download and build the prosthesis to test various powered control systems—with an ultimate goal of solving challenges associated with controlling bionic legs. By Christine Umbrell

26 | This Just In

Six Suggestions for Putting Patients First

P. 26

In response to CMS’s June request for information regarding the Patients Over Paperwork initiative, AOPA has offered several recommendations for prioritizing patients. Learn why AOPA is advocating for implementing Section 427 of the Benefits Improvement and Protection Act, recognizing O&P documentation, revising reasonable useful lifetime rules for orthoses, and more.

40 | High-Tech and High-Touch O&P master’s students are going in-depth into studies of new technologies and research, and they’re getting up-close-and-personal in working with patients, fabricating devices, and learning successful business strategies. Find out which topics are high priority for tomorrow’s clinicians studying at today’s O&P programs. By Meghan Holohan


48 | Making Waves

P. 48


Attendees at the AOPA National Assembly in San Diego will immerse themselves in high-profile clinical and business education during the presentation of the 2019 Thranhardt and Hamontree Awards. This year’s honorees will present the latest findings on cranial remolding orthoses, the use of health economic instruments to evaluate prosthetic services, and a variety of best business practices. Plus, find out who is being recognized with 2019 Lifetime Achievement and Legislative Advocacy Awards. By Deborah Conn

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DEPARTMENTS Views From AOPA Leadership......... 6 David A. Boone, BSPO, MPH, PhD, on boosting O&P research initiatives

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

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


Research, updates, and industry news

Josh Caputo, PhD................................................. 54

People & Places........................................18

Meet a Carnegie Mellon University graduate who built on the work from his doctoral thesis on the development of a robotic ankle-foot testbed to start his own R&D company.

Transitions in the profession

COLUMNS Reimbursement Page........................ 20

Return Policies

Tips for billing returned and refused O&P componentry CE Opportunity to earn up to two CE credits by taking the online quiz.


P.20 P.12

AOPA News.............................................. 62 AOPA meetings, announcements, member benefits, and more

O&P PAC Update .................................. 64 Welcome New Members.................. 66 Careers........................................................ 68 Professional opportunities

P.60 Member Spotlight................................. 58

P.58 4



Liston Prosthetics


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Marketplace.............................................. 72 Ad Index...................................................... 77 Calendar...................................................... 78 Upcoming meetings and events

Ask AOPA.................................................. 80 Bid surety bonds, site inspections, and more



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Hungry for Sound O&P Research


N OLD JOKE IN our profession goes something like this: “Every CPO is still looking for the world’s second best CPO.” That might make it sound like we are all pretty full of ourselves, our knowledge, and skills, but I’ve always thought that it more positively and accurately conveys how we take ultimate responsibility to be doing the best we feel can be done for our patients. In striving to do our best, we naturally build up our own armamentarium of “what works.” Even the economic pressures of what will be reimbursed factor into clinical decision making, filling voids where scientific evidence of what would be best is lacking. Sometimes this attitude can be a hindrance to accepting research outcomes, when new research may not fit with the view of the O&P world we have built up in the successful practice of patient care. That is the exception, Sound research, though. Happily, as a researcher, my has been that some of our carefully considered, experience oldest and most skilled clinicians are excellent role models for progressive will bring us more care and have been most supportive of and hungry for research. I hope confidence that that we all stay open to constantly adjusting what we think we know. we are providing Similarly, our scientist sisters optimal patient care. and brothers in the profession need to understand that experimental results are just that—observations from an experiment that usually has many limitations. Tremendous care must be taken to understand how new observations fit with the old—and not just replace them. They rarely, if ever, do so. We must stay vigilant to the limits of any research findings, even as we tout them and celebrate new knowledge. So, if we are careful consumers, research helps us make sure that we are on the right side of the joke I shared. Sound research, carefully considered, will bring us more confidence that we are providing optimal patient care. In doing so, we also are doing the best for our profession in challenging times. Independently derived evidence is the one currency that will best convey our message of quality care to policy makers. David A. Boone, BSPO, MPH, PhD, is 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


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

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,

Joe McTernan, director of coding and reimbursement services, education, and programming, 571/431-0811,

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

Reimbursement/Coding: 571/431-0833,


Joy Burwell, director of communications and marketing, 571/431-0817,

Ashlie White, MA, director of strategic alliances, 571/431-0812,

Betty Leppin, manager of member services and operations, 571/431-0810,


Kelly O’Neill, CEM, manager of membership and meetings, 571/431-0852, Ryan Gleeson, CMP, assistant manager of meetings, 571/431-0836, Yelena Mazur, communications specialist, 571/431-0835, Kristen Bean, membership and meetings coordinator, 571/431-0876, AOPA Bookstore: 571/431-0876 8

Devon Bernard, assistant director of coding and reimbursement services, education, and programming, 571/431-0854,


Eve Lee, MBA, CAE, executive director/publisher, 571/431-0807, Josephine Rossi, editor, 703/662-5828, Catherine Marinoff, art director, 786/252-1667, Bob Heiman, director of sales, 856/673-4000, Christine Umbrell, editorial/production associate and contributing writer, 703/6625828,

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 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. COVER PHOTO: Barbara Ries Photography/UCSF

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 Visit for advertising options!


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More Americans Seek Nontraditional Healthcare Options Report finds Americans ages 18 to 37 are least satisfied with traditional healthcare services Younger healthcare consumers, including Gen Z (born 1997 and later) and millennials (born 1981 to 1996), are less satisfied than older Americans with the quality of traditional healthcare services, according to the “Accenture 2019 Digital Health Consumer Survey.” The report found that consumers of all generations have become more willing to try nontraditional services, which include virtual health (via phone, video, or app), on-demand services, walk-in or retail clinics, outpatient surgery hospitals, and digital therapeutics.


77 Percent

69 Percent

Would like to receive email or text reminders regarding follow-up care

68 Percent

Would like to communicate with providers via secure email

53 Percent

Would like to book and cancel appointments online

Would like to use remote or telemonitoring devices to record health indicators

49 Percent

Would like to communicate with providers via videoconference













Dissatisfied with effectiveness of treatment



Dissatisfied with transparency of cost

Factors That Influence Decisions About Choosing a Specific Provider Accepts my insurance


Low cost to me


Convenient location


Reputation for providing superior care

16% 13%

Recommendation from a health provider Short wait time to secure an appointment


Short wait time on day of visit


Recommendation from friend or family









Dissatisfied with wait time and speed of appointment

“Compared with older generations, younger consumers are much more likely to choose medical providers who offer digital capabilities such as easy access to test results via mobile or online and requesting prescription refills electronically.” —“Accenture 2019 Digital Health Consumer Survey”

SOURCE: “Accenture 2019 Digital Health Consumer Survey,” Accenture Consulting.

Dissatisfied with transparency about care (e.g., what test will be conducted)


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Design Team Develops Exoskeleton Hand for Stroke Patients



Biomedical engineering researchers at the University of Utah have developed a methodology for the robotic LUKE Arm to mimic the way a natural hand feels objects by sending the appropriate signals to the brain, via biomimetic sensory feedback. A team led by Gregory Clark, PhD, has created a system that allows the advanced prosthesis—an artificial limb developed by DEKA Research & Development Corp. that is powered by an external battery and wired to a computer—to tap into the wearer’s nerves via a new device called the Utah Slanted Electrode Array. The array comprises 100 Keven Walgamott tests the new microelectrodes and wires that are prosthetic arm system that incorporates implanted into the amputee’s nerves peripheral nerve stimulation. in his or her forearm and connected to a computer outside the body. impulses from a primate’s arm, to The new system has been designed create an approximate model of how to enable the prosthetic hand to “feel” humans receive these different signal an object to assess how much pressure patterns. That model was then impleto exert. Sensors in the prosthetic mented into the LUKE Arm system. arm send signals to the nerves via the “We changed the way we are sending array to mimic the feeling a natural that information to the brain so that hand experiences upon grabbing an it matches the human body. And by object. With this design, the researchers matching the human body, we were able sought to re-create how, upon inito see improved benefits,” said Jacob tial contact of an object, a “burst of George, a graduate student and one of impulses runs up the nerves to the Clark’s team members. “We’re making brain and then tapers off,” according more biologically realistic signals.” to a University of Utah press release. The research team has been testing “Just providing sensation is a big deal, the prototype on study subject Keven but the way you send that information Walgamott, who lost his left hand and is also critically important, and if you part of his arm 17 years ago. Early results make it more biologically realistic, the indicate Walgamott is able to move brain will understand it better and the LUKE Arm’s prosthetic fingers via the performance of this sensation thought control, and he has been able will also be better,” said Clark. to pick up an egg without crushing Clark’s team used mathematical it. Research findings were published calculations, along with recorded in the July issue of Science Robotics.

PHOTO: University of Utah Center for Neural Interfaces

Researchers at the Centre for Mechatronics at the Indian Institute of Technology—Kanpur have completed trials of a robot exoskeleton hand designed to aid in the rehabilitation of stroke patients. Professors Ashish Dutta, PhD, and K.S. Venkatesh designed a two-finger device that can be worn by a patient on his or her hand. Using sensors that monitor the fingertip pressure applied by the patient, the exoskeleton can interpret brain signals via a braincomputer interface worn on the head. The device, which features a four-bar mechanism and four degrees of freedom, reportedly enables paralytic users to open and close the motion of their thumb, index finger, and middle finger during rehabilitation exercises. The research was published in the Journal of Neuroscience Methods. Dutta and Venkatesh plan to expand studies to enable more activities among users.

Utah Researchers Enable Prosthetic Hand Movement Via Peripheral Nerve Stimulation


2018 AOPA Free Paper Findings Published in Journal of Clinical Medicine


A free paper presented at the 2018 AOPA National Assembly by Tiffany Graham, CPO, LPO, MSPO, FAAOP, “Outcome Effects of Initial Age and Severity in Cranial Remolding Orthotic Treatment for Infants With Deformational Plagiocephaly,” has been adapted and published in the July 24 issue of Journal of Clinical Medicine. The article, which was co-authored by Beverley Adams-Huet, MD; Nicole Gilbert; Kirsten Witthoff; Terran Gregory; and Mary Walsh, describes a retrospective chart review of 499 infants with nonsynostotic plagiocephaly who completed cranial remolding orthotic treatment. Overall, treatment times tended to statistically increase with older infants and those with more severe initial cases of the condition. Post-treatment asymmetry measurements statistically trended to greater residual deformation in infants who began treatment in the

Rob Jones, a Marine veteran and double amputee, announced his campaign for the 10th Congressional District of Virginia. He made the announcement in July on the nine-year anniversary of the day he lost his legs during in an IED explosion in Afghanistan. Should he become the Republican nominee in spring 2020 and get elected, he would join several amputees already in Congress, including Sen. Tammy Duckworth (D-Illinois) and Rep. Brian Mast (R-Florida). After his injury, Jones relearned how to walk, run, bike, and row using prostheses. He has participated in marathons, biked across the country, raised money for veterans’ charities, and competed in the Paralympic Games. If elected, he hopes to work on improving the Virginia infrastructure as well as focus on veterans' issues. “As a veteran, I think we’re definitely beginning to see the [U.S. Department of Veterans Affairs] improve a lot," he said, adding that he would like to push to offer veterans more choices on where they can receive healthcare.

older or more severe subcategories. This indicates that younger infants with less severe deformities experience shorter treatment durations and less residual cranial deformation after orthotic intervention, according to the authors. Graham will be speaking on “Significant Factors in Orthotic Treatment of Asymmetrical Brachycephaly” during the Thranhardt presentations at the 2019 National Assembly in San Diego. (See page 48 for details.)

ACL Announces Research Funding Opportunities A recently announced initiative from the Administration for Community Living (ACL), the Disability and Rehabilitation Research Projects (DRRP) funding program, supports projects that carry out one or more of the following activities: research, development, demonstration, training, dissemination, utilization, and technical assistance. The purpose of the DRRP program is to plan and conduct research, demonstration

projects, training, and related activities to develop methods, procedures, and rehabilitation technologies that maximize the full inclusion and integration of individuals with disabilities into society, employment, independent living, and family support, and to promote economic and social self-sufficiency and improve the effectiveness of services authorized under the Rehabilitation Act. Details are available on the ACL website at

Former Marine Seeks Office in Virginia





Amputee Coalition Releases Whitepaper on Limb Loss Research The Amputee Coalition has published “Roadmap for Improving Patient-Centered Outcomes Research and Advocacy,” a whitepaper that features recommendations from the 2018 Limb Loss Task Force, convened by the Amputee Coalition and the National Limb Loss Resource Center. The whitepaper, available for download from the Amputee Coalition website, amputee-coalition. org, documents the activities of the task force and emphasizes the need for more research on amputation care, which “has been underscored by coverage and reimbursement policy decisions made by insurance companies that have restricted access to prosthetic care,” according to the whitepaper. The document outlines several recommendations to boost research for the limb loss population, including building a limb loss research collaborative, advocating for increased funding, and encouraging research that addresses the question, “What is a successful outcome?” The Amputee Coalition plans to develop a strategic plan for implementing and disseminating research; work with researchers to identify ongoing outcomes of significance; and organize a day on Capitol Hill to raise awareness of the issues surrounding research disparities and access to care challenges.




Demographics Shift Among ACA Health Insurance Enrollees CMS announced in August that enrollment in health insurance plans via the exchanges created by the Affordable Care Act (ACA) declined by 1.2 million people, or 24 percent, between 2017 and 2018 among people with incomes too high to qualify for ACA subsidies. During the same period, enrollment increased by 300,000 people among those with lower incomes who did qualify for financial help under the legislation. Since 2014, average monthly enrollment in the subsidized portion of the market has grown substantially larger than in the unsubsidized market, according to CMS. The subsidized portion of the market was 122 percent larger than the unsubsidized portion in 2018, up from 61 percent larger in 2017. When the subsidies, officially known as advanced payments of the premium tax credits (APTC), first became available in 2014, average monthly enrollment in the individual market was about 8.4 million members, of which 4.6 million enrolled with APTC subsidies and 3.7 million enrolled without APTCs. Enrollment rose by 63 percent in 2015 to 13.6 million members, and rose another 7 percent in 2016 to 14.5 million members.

States With Largest Drops in Unsubsidized Enrollees

However, this trend reversed from 2016 to 2017, when enrollment declined by 10 percent. Enrollment declined another 7 percent from 2017 to 2018. The decline in enrollment in 2017 and 2018 is occurring at the same time as sharp increases in average monthly premiums, according to CMS data, and may mean that more Americans are currently uninsured. Certain states have experienced particularly significant decreases in enrollment. Between 2016 and 2018, unsubsidized enrollment dropped by 91 percent in Iowa, 79 percent in Arizona, 78 percent in Nebraska, 76 percent in Tennessee, 71 percent in Georgia, and 71 percent in Oklahoma.


CMS Announces Proposed Rule With Implications for Gap-Filling Methodologies CMS in August released a proposed rule to update the end-stage renal disease (ESRD) Prospective Payment System. Major changes to the gap-filling methodology were included in the proposed rule. The O&P community could be affected if the rule were to be enacted because gap filling is the current procedure used when newly introduced products and Health-Care Common Procedure Coding System codes receive a fee schedule amount. AOPA staff is currently reviewing the proposed rule in detail and will provide more information in the next issue of O&P Almanac.




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NFL Linebacker Surprises Fan With Limb Loss



Americans Surprised By Unexpected Medical Bills Four in 10 insured nonelderly adults said they received an unexpected medical bill in the past 12 months, including one in 10 who said that bill was from an out-of-network provider. Of those who received an unexpected bill, half said the amount they were expected to pay was less than $500 overall while 13 percent said the unexpected costs were $2,000 or more. —“An Examination of Surprise Medical Bills and Proposals To Protect Consumers From Them,” Peterson-Kaiser Health System Tracker, June 2019



PHOTO: Challenged Athletes Foundation ®

Shaquem Griffin, a linebacker for the Seattle Seahawks and have every choice to make. You got every decision to make the first arm amputee to play in the National Football League, and say, ‘You know what? I’m going to attack this day. I will recently joined the Challenged Athletes Foundation® (CAF), not let the day attack me.’ So, get up, be positive, attack it, be Össur, and Nike to surprise 10-year-old Izzy Turkington from great; because the only person that can stop you is you.” Salem, Oregon, with a customized pair of Össur Flex Run Junior with Nike Sole running prostheses. Griffin met with Turkington during an Össur Mobility Clinic presented by CAF. Turkington, who was born with quad congenital limb differences, is an active athlete who enjoys playing soccer, running, surfing, and caring for animals. Griffin had his left hand amputated at age 4 due to amniotic band syndrome, played defensive back at the University of Central Florida, and was named the 2018 Peach Bowl Defensive MVP before being selected by the Seahawks in the 2018 draft as a fifth round pick. He spoke to the NFL linebacker Shaquem Griffin worked with 10-year-old Izzy Turkington crowd at the clinic in Oregon, saying, during an Össur Mobility Clinic in Oregon. “You wake up in the morning—you

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Isaac Bunn

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Isaac Bunn and Kathleen Spaeth are new additions to the staff of the Board of Certification/ Accreditation (BOC). Bunn is BOC’s credentialing liaison and will be responsible for providing administrative support to the credentialing, facility accreditation, and marketing/business development teams. Spaeth is the new marketing communications manager and is responsible for developing and executing marketing and communications initiatives to promote BOC products and support the BOC brand.

Jeff Dawson and Leon Owens have been named product sales specialists at Fillauer for the company’s Northeast and Southeast regions, respectively. Dawson and Owens will focus on continued Jeff Dawson sales growth for Fillauer’s orthotic and prosthetic product lines, as well as tools and equipment. They both report to Erin Myers, regional manager for the Eastern United States. “We are thrilled to have Leon and Jeff join our sales team and look forward to their future success,” said Traci Dralle, Leon Owens president of Fillauer Companies Inc. “Over the past two years, we have built a talented sales team that reflects our mission and values. They all share tremendous sales and customer relationship-building experience and work very well as a cohesive team.”

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Return Policies Billing tips for returned and refused orthotic and prosthetic components

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 22 to take the Reimbursement Page quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.









OW TO BILL FOR returned and

refused items remains one of the top 10 questions AOPA receives. This month’s Reimbursement Page examines the billing issues related to returned and refused items—also known as salvage claim billing—and provides tips and guidelines to help you with these situations.

Refused Devices

In the world of O&P, “refused” can have more than one meaning. An orthotic or prosthetic device is considered refused if a patient voluntarily decides not to return for a final fitting or does not pick up the completed item. An item also may be considered refused if the patient is unable to accept delivery because the item is no longer medically necessary. A refusal based on medical necessity could be the result of a change in a patient’s condition. For example, a physician may order a lumbosacral orthosis (LSO) for a patient—but before you are able to deliver the LSO, the patient may decide to have surgery instead. Because the patient has chosen a different means of treatment, the brace may no longer be needed—or medically necessary—and may be refused. In addition, if a patient passes away before you can deliver an item, the item is no longer considered medically necessary and may be deemed a refused item. Once you have established that a

patient has refused an item, either by his or her own choice or by the fact that the item is no longer medically necessary, you then must determine what you may be able to bill to Medicare and decide what you will use as the date of service; billing for refused items is one of the rare instances in which the date of service will not equal the date of delivery because there is no actual delivery. To accomplish these two tasks, you must establish when you learned of the refusal, what type of item was going to be delivered (prefabricated or custom fabricated), and whether fabrication was completed when you learned of the refusal. The date you learned about the refusal will become the date of service for billing purposes. If the patient voluntarily refused the item (did not respond to attempts to schedule a final delivery), your date of service would be the last day you attempted to deliver the item. While there are no rules stating that you must make X number of attempts before you declare an item refused, it is recommended that you make at least three attempts—and be sure to document all attempts you made to deliver the item. If you were able to contact the patient, and he or she informed you that he or she no longer wants the item, that day would be the date of service. If the patient has passed away, your date of service is the date of the patient’s passing and not the date you


learned of the passing—because most likely that will be after the patient has passed. If you use a date of service that is after the date of the patient’s death, your claim will be denied. If the item to be delivered is custom fabricated, was the fabrication completed, or were you still fabricating the item when you learned of the refusal? If you have completed fabrication, you may bill for the complete item, except for any components that may be salvaged and reused or returned to the manufacturer for a refund. For example, if you are fabricating a belowknee prosthesis and fabrication was completed when you learned of the refusal, but you can return the foot to the manufacturer for a refund, then you may bill for everything except the foot because the foot was salvageable. If the custom fabrication process was not completed when you learned of the refusal, you may bill only for the work that you completed up to the point you learned of the refusal. For example, if you are fabricating an above-knee prosthesis

and all you had completed is a test socket when you learned of the refusal, you could submit a claim for the test socket. However, if you were fabricating an ankle-foot orthosis (AFO) and everything was finished except for attaching the lining/padding, you could bill for the complete AFO base code—but you could not bill for the addition code of the lining/padding. Once again, you may not bill for any parts and components that may be salvaged and reused. If the item to be delivered is prefabricated, you may not have the ability to bill Medicare because you may have the option to return the item to your stock and reuse it for a different patient, or you may have the ability to return it to the manufacturer for a refund. If the prefabricated item has been modified or altered and cannot be returned to stock to be used with a different patient or returned to the manufacturer, you may consider it like a custom-fabricated item for billing purposes—meaning you may bill for all of the work you completed up to the time you learned of the refusal.

Once you have determined that the item has been refused and you have the ability to submit a claim to Medicare, simply submit the claim as you normally would. Remember to include any of the modifiers that are required by policy (KX, LT, RT, GA, K1, K2, etc.), but note there is not a special modifier to indicate that the claim is being billed as a refused item. Consider including a brief statement in the narrative field of the claim indicating that you are billing for a refused item and explaining why the item is considered refused. Occasionally, a claim may be denied because at the time of death the patient was in a hospital or a skilled nursing facility. In these cases, you would have to appeal the denial and explain that you are billing the item as a refused item due to the patient’s passing, that the item was not actually delivered, and that it was intended to be delivered outside of the facility setting. You may use the Medicare Benefit Policy Manual, Chapter 15, Section 20.3, to bolster your argument.




for a refund of a patient’s returned item, you must then refund the money; however, you may then appeal the refund and show that you provided what was ordered and made good-faith attempts to satisfy the patient. This is where documentation of how you tried to satisfy the patient will come into play.

Storage Rules

Returned Devices

The process of handling and billing returned items—or those items that have been brought back to you by the patient after delivery—is more complicated than the process for refused devices because you must directly address and comply with specific Supplier Standards. Supplier Standard 15 states that a supplier must accept returns of substandard items (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries. If a patient returns an item, it is up to you to prove that the item was not substandard and that the item was suitable and appropriate for what was ordered. One way to facilitate this would be to consider asking patients to sign a delivery slip with a statement indicating they are satisfied with the item at the time of delivery. And if patients have concerns, document those concerns—along with what you did to address them. In addition, document all subsequent encounters with the patient, including all attempts that you made to make the device satisfactory to the patient’s requests. Also, ensure that your initial order and your final detailed written order clearly indicate what item was ordered, as this will help to demonstrate—along with your documentation and the referring physician’s documentation—that the 22


item provided was “appropriate” for the patient at the time it was ordered and delivered. In other words, you can show that you provided exactly what the physician ordered, meaning it was suitable. You also will need to consider Supplier Standards 13 and 20. Standard 13 states: “A supplier must answer questions and respond to complaints of beneficiaries and maintain documentation of such contacts.” Standard 20 states: “Complaint records must include the name, address, telephone number, the health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it.” In many cases, if a patient is attempting to return an item, complaints will be involved—so be sure you complete a complaint log, when appropriate, even if the “resolved actions” involved accepting the return and issuing a refund. Handling and billing for returned items also is tricky because, in many cases, returned items may involve an overpayment request. If the item cannot be adjusted to satisfy the patient and he or she still returns the item, and you have already billed for the item and received payment, you are under no obligation to make a refund to the patient at the time he or she returns the item. The only time you must refund the money is when Medicare sends you a formal overpayment request. If you receive an official Medicare overpayment request

Do not destroy or dispose of any returned or refused items after you have billed for them and received payment for them—at least not immediately. If the patient decides he or she wants the item, or it becomes medically necessary again, you must be able to provide the patient with the item because you billed and collected payment for it. If you no longer have the item, you are required to provide the patient with the exact item you billed for, but you will not be able to charge the patient for the second component. It is up to you to determine how long to keep refused or return items before disposing of them. Hold onto the devices for as long you feel is appropriate, or until you believe the patient will no longer want the item. For example, if the patient has passed away, there would not be a need to retain the item for very long, and it may be appropriate and safe to dispose of the item after billing. Knowing the rules and billing accordingly will help ensure you are appropriately reimbursed—when possible—for returned and refused items. Devon Bernard is AOPA’s assistant director of coding and reimbursement services, education, and programming. Reach him at Take advantage of the opportunity to earn two CE credits today! Take the quiz by scanning the QR code or visit Earn CE credits accepted by certifying boards:

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This Just In

Six Suggestions for Putting Patients First AOPA recently provided feedback to CMS regarding the Patients Over Paperwork initiative


N JUNE 11, CMS published a request for information (RFI) in the Federal Register. The RFI is part of CMS’s Patients Over Paperwork initiative, launched in 2017 as part of an executive order to reduce red tape in federal agencies and ease regulations that are deemed burdensome. In the new RFI, CMS sought comments on ideas for “regulatory, subregulatory, policy, practice, and procedural changes that reduce unnecessary administrative burdens for clinicians, providers, patients, and their families.” This is the second RFI under the Patients Over Paperwork initiative. The first RFI was very successful: CMS received 3,000 responses, which highlighted more than 1,000 possible areas and topics to reduce the burden on providers, suppliers, and patients. The June 11 RFI was focused on concepts that had been reported during the first RFI, with an emphasis on, but not limited to, these key points: • Improve the accessibility and presentation of CMS requirements



for quality reporting, coverage, documentation, or prior authorization. • Address specific policies or requirements that are overly burdensome, that are not achievable, or that cause unintended consequences in a rural setting. • Clarify or simplify regulations or operations that pose challenges for beneficiaries dually enrolled in both Medicare and Medicaid and those who care for such beneficiaries. • Simplify beneficiary enrollment and eligibility determination across programs. AOPA strongly supports CMS’s efforts to prioritize patients over paperwork through the reduction of unnecessary and redundant administrative burdens that are placed on physicians and allied health providers who deliver medically necessary services to Medicare beneficiaries. AOPA responded to the RFI and submitted comments with several key suggestions or asks. Here are six of those suggestions:

This Just In


Implement BIPA

CMS should promulgate regulations to implement Section 427 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA). The statutory language in Section 427 of BIPA instructed CMS to take the necessary regulatory steps to ensure that Medicare beneficiaries receive prostheses and custom-fabricated orthoses from qualified providers and suppliers—those that are properly trained, educated, certified, and/or licensed to safely provide them. AOPA stressed that the provision of prostheses and custom-fabricated orthoses to Medicare beneficiaries must be limited to individuals or entities that are truly qualified to do so. AOPA also acknowledged that in the 19 years that have elapsed since the passage of BIPA 2000, Medicare has changed, as has the practice of providing prostheses and customfabricated orthoses. Recognizing that passage of time while staying true to

the original intent of the statute, AOPA suggested that CMS develop regulations that implement the qualified provider provisions of BIPA 427 in a way that protects Medicare from fraud and abuse by unqualified providers while ensuring Medicare beneficiaries maintain access to medically necessary prostheses and orthoses provided by properly educated and trained allied health professionals.


Recognize O&P Documentation

CMS should fully recognize the value of the prosthetist’s and orthotist’s clinical documentation when performing claim reviews and audits. AOPA pointed out that Medicare contractors continue to require excessive clinical documentation in the referring physician’s notes when performing medical review functions for Medicare claims— even though Section 50402 of the Bipartisan Budget Act of 2018 stated, “For purposes of determining the

reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by eligible professionals described in Section 1848(k)(3)(B).’’ In its comments, AOPA stated that Section 50402 of the Bipartisan Budget Act of 2018 created a statutory pathway that allows the clinical documentation of the orthotist or prosthetist to be considered part of the patient’s medical record for purposes of medical review. CMS can significantly reduce unnecessary documentation burdens on physicians and nonphysician practitioners by instructing its contractors to fully acknowledge the relevance of clinical documentation created by orthotists and prosthetists and require physicians and nonphysician practitioners to only maintain documentation that addresses the general medical necessity of the orthoses and prostheses they prescribe.



This Just In


Reconsider RULs for Orthoses

AOPA commented on the idea that CMS should consider revising the reasonable useful lifetime (RUL) for orthoses. The Social Security Act states that the RULs of durable medical equipment (DME), prosthetics, and orthotics are determined by program instructions. It goes on to state that in the absence of program instructions, the RUL of these items can be no less than five years.

The volumes of documentation that must be maintained by the certifying physician, prescribing physician, and provider of the shoes have led many providers to determine that the reimbursement for diabetic shoes and inserts is simply not enough to cover the cost of obtaining and maintaining the required documentation. BIPA 2000 added language that indicated that prosthetic devices were not subject to the five-year RUL requirement and could be replaced at any time if there was established medical need for the replacement. CMS also issued program instructions that reduced the RUL of knee orthoses to one year for most prefabricated knee orthoses, two years for certain custom-fitted knee orthoses, and three years for some custom-fitted knee orthoses and all custom-fabricated knee orthoses. AOPA’s comments stressed the belief that the current RUL of five years for most orthoses is unrealistic for orthoses that are worn daily and 28


are subject to forces that constantly expose the orthosis to harsh environmental conditions and rigorous physical stress. AOPA requested that CMS, which does have the authority to develop program instructions that would create more realistic RULs, develop program instructions that reduce the RUL of orthoses to more realistic time frames such as those that currently apply to knee orthoses or lower-limb prostheses. This idea would allow Medicare beneficiaries to replace worn orthoses that meet their medical need but no longer function due to extensive use.


Require CERT Contractors To Staff a Certified Clinician

CMS should require Comprehensive Error Rate Testing (CERT) contractors to employee a certified/licensed prosthetist/orthotist. AOPA recommended that CMS require CERT contractors that review paid claims for orthoses or prostheses to recruit and hire certified and/or licensed orthotists and prosthetists who can properly guide the review process to ensure that a reasonable review decision is made. The employment of a certified/ licensed orthotic and prosthetic professional is not without precedent as most of the DME Medicare administrative contractors currently have O&P professionals on staff, as does the current Region 5 Recovery Audit Contractor. In addition, the Pricing, Data Analysis, and Coding contractor is required to employ a certified and/or licensed orthotist/prosthetist as a condition of its contract with CMS.


Reduce Documentation Burden for Diabetic Shoes

CMS should reduce the documentation burden associated with the provision of diabetic shoes. AOPA recognized that there are specific statutory requirements that limit the actions that CMS may take to reduce the administrative burden associated with the provision of therapeutic shoes

and inserts but encouraged CMS to review how it may reduce the burden and prioritize patients over paperwork. AOPA stressed that the volumes of documentation that must be maintained by the certifying physician, prescribing physician, and provider of the shoes have led many providers to determine that the reimbursement for diabetic shoes and inserts is simply not enough to cover the cost of obtaining and maintaining the required documentation. As a direct result of the unreasonable and redundant documentation requirements to support Medicare coverage of diabetic shoes and inserts, many providers have decided to no longer offer this service as part of their business. This has created a shortage of providers of diabetic shoes and inserts, which has led to significant access-tocare issues for Medicare beneficiaries who rely on therapeutic shoes and inserts to prevent further complications of diabetes, which could result in amputation of all or part of the feet.


Review Prior Claims History During Medical Necessity Determinations

AOPA recommended that CMS authorize its contractors to review prior claims history when making a medical necessity determination. CMS already captures and maintains extensive data regarding treatment and care of its beneficiaries, and CMS should authorize its contractors to utilize this data to assist in establishing medical necessity for services provided to Medicare beneficiaries. Using established data within the patient’s CMS data file would eliminate the need for redundant documentation from the medical record of the prescribing physician as well as the provider of the service.

Detailed Comments

The six suggestions described above provide a summary of some of the information provided in AOPA’s response to CMS’s RFI. To view AOPA’s complete comments, visit



INNOVATION Researchers take a collaborative approach to designing a smart prosthetic leg for advancing lower-limb control strategies By CHRISTINE UMBRELL

NEED TO KNOW Some O&P researchers are embracing an open innovation approach to advancing the profession. Elliott Rouse, PhD, is one such inventor. He recently developed an OpenSource Leg, a “smart” robotic prosthesis geared specifically toward researchers who want to test powered control systems, and made the design plans available online. Once the design parameters for the Open-Source Leg were published, groups at several institutions downloaded the design and assembled their own robotic legs with a goal of efficiently solving challenges associated with controlling bionic legs across a range of activities. The project designers anticipate that the open-source approach will unite researchers with a common hardware platform and enable new investigators from related fields to develop innovative control strategies.



Researchers at the Shirley Ryan AbilityLab, Carnegie Mellon University, the University of Texas at Dallas, and Georgia Tech have all assembled a robotic leg using the open-source design and have tested their control strategies on the prosthesis. This approach keeps communication open between the institutions that are leveraging the design regarding the powered leg itself—but allows each group to keep its research findings private until the studies are complete, using traditional publication processes to share results in due time. As the research stemming from testing of control systems on the Open-Source Leg leads to advances in powered control of lower-limb prostheses, the development of improved artificial limbs is expected to follow. With open innovation becoming more popular across many industries as a means to lower the barriers to entry, accelerate R&D initiatives, and solve problems in a more collaborative way, O&P may soon see more open-source research tools.




and funding agencies are increasingly encouraging the use of open innovation and open science approaches to research and development (R&D). These practices allow for purposely managed knowledge flows across organizational and industry boundaries, and embrace processes for facilitating knowledge flows across companies, users, and universities. O&P’s first foray into open R&D began with the advent of 3D printing. Several years ago, the debut of additive manufacturing resulted in some innovators leveraging open source programs to share designs for 3D-printed hands online—which led to rudimentary prostheses being built for children and amputees in developing countries. A more collaborative approach to O&P R&D also manifested in the creation of maker spaces, such as Ottobock’s Open Innovation Space in Berlin. These facilities enable a more distributed, more participatory, and more decentralized approach to innovation. Spaces such as these serve as incubators for hardware and software developers, as well as designers, artists, and inventors. The latest example of open innovation in the United States is the development of an open-source “smart” prosthetic leg that is available to the scientific community for R&D purposes. This project—Open-Source Leg—enables researchers to test different control systems for powered prostheses. Working with scientists at the University of Michigan (UM) and Shirley Ryan AbilityLab, Elliott Rouse, PhD, created a prototype featuring a modular design that can act as a knee, ankle, or both. Anyone can visit the project website (https://opensourceleg. com/) and learn where to get the materials, how to put the leg together, and how to use and control it, says Rouse, who is an assistant professor in the UM Department of Mechanical Engineering and a core faculty member in the Michigan Robotics Institute.




To date, researchers at several institutions—including the Shirley Ryan AbilityLab, Carnegie Mellon University (CMU), the University of Texas at Dallas (UT Dallas), and Georgia Tech— have downloaded the design, built the componentry, and begun to test control systems. Ultimately, the goal is to advance the science and develop control systems that will improve prosthetic design for lower-limb patients.

A Novel Approach

A researcher at the University of Michigan College of Engineering works on the Open-Source Leg.

The idea for the Open-Source Leg “came from discussions with other Hargrove’s group has spent the past controls researchers in the field” who decade developing artificial inteldesired to study advanced control ligence-based control systems for strategies but found that prosthetic powered legs. Rouse and Hargrove hardware was costly or realized there could be benefits unavailable, says Rouse. His to bringing together probUM group is focused on lem-solvers from many corners “reverse engineering how to study prosthetic control. humans control locomoHigh-level control of powered tion,” which serves as a prostheses is “such a challenge blueprint for his robotic that we need the best minds Elliott Rouse, prostheses and exoskeleworking on it,” says Rouse— PhD tons, and he sought a way and developing a design that to design a robotic leg that could be various control systems could be used for research purposes across tested on seemed an ideal solution. several institutions, making it easier to Rouse led the design of the hardcompare results. “To solve problems ware and low-level control, discussing in wearable robotics, you need to be on design constraints and specifications the forefront of many fields all at once, with Hargrove and other researchers. which I find exciting,” Rouse explains. “We saw the need that hardware is Early on, Rouse worked closely expensive to design, and we thought with Levi Hargrove, PhD, director a lot of people could use it,” says of the Regenstein Center for Hargrove. “It’s sort of a service to the Bionic Medicine at the Shirley community, and we wanted to push our Ryan AbilityLab and a professor own research forward.” at Northwestern University. Hargrove says they drew inspiration



PHOTOS: University of Michigan College of Engineering

Elliott Rouse, PhD, works with a subject equipped with the Open-Source Leg.

from the upper-limb field, “where we see a lot of open-source 3D-printed hands.” They wanted the Open-Source Leg to be well-engineered, but they decided they could also “make the files and instructions on how to assemble it available to the community,” he says. Seeking funding, Rouse submitted a proposal to the National Science Foundation (NSF) three years ago, collaborating with Hargrove’s team as well as groups at CMU and UT Dallas that both had control strategies they wanted to test using the new device. Once NSF agreed to fund the project as part of the NSF National Robotics Initiative, “we started presenting about it at a few meetings,” and more researchers began looking at the open-source files, says Hargrove. There are currently six groups working with the Open-Source Leg for research endeavors, all of which are conducting studies to make powered legs safer and more reliable, with advanced control capabilities.

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PHOTOS: Shirley Ryan AbilityLab

powered prosthetic legs, according to Hargrove. With the methodologies groups testing their different systems using the exact same robotic leg, “we can then look at pros and cons of each other’s control strategies,” explains Hargrove. “We’re doing it in an academic, collegial way.” At the Shirley Ryan AbilityLab, Hargrove’s team has made significant progress in developing its control system since it began testing on the open-source design. “We’ve probably had 15 transfemoral amputees, both men and women, K3- and K4-level ambulators, over the past year walking on it,” says Hargrove. “We’re doing some community outcomes testing, not necessarily in the lab but always under Engineers in Shirley Ryan AbilityLab’s Center for Bionic Medicine supervised use,” he explains, as the prepare the Open-Source Leg for a session with a research subject. device is untethered but still requires supervision under use. The current prototype is “a and out in the community,” says Rouse. This approach keeps communihigh-end, state-of-the-art machine,” “In addition, we hope our bionic leg cation open regarding the powered even though the designs and code are will unite researchers with a common leg itself but allows each institution free, Hargrove explains. “It’s a unique hardware platform and enable new to keep its research findings private plug-and-play system that allows investigators from related fields to until the studies are complete—using scientists to avoid R&D costs in the develop innovative control strategies. traditional publication processes to millions of dollars and immediately “This is really intended share results in due time. begin testing on prosthetics for the for researchers and is not “We’re keeping independent, knee and ankle. It effectively lowers a commercial product,” he doing academic research, the barriers to entry for researchers,” explains. It’s for “people and making results available as investigators are no longer required like me who want to study through the academic chanto invest the prohibitive time and the highest level of control,” nels,” Hargrove says. monetary cost of developing their own Rouse says. The end goal, “At the same time, any Levi Hargrove, powered prostheses from scratch. according to Rouse, is to sort of mechanical improvePhD “get this technology to the ment to the leg that can Advanced Problem Solving community and to get us be made—we’re reporting With the development of the Opencloser to [a patient] wearing a powered that to the Open-Source Leg group,” Source Leg, investigators at the instiprosthetic leg in their daily life.” which means less time spent troututions involved in the NSF project, Approaching the research this way “is ble-shooting for other groups. When as well as researchers at several other uniting a fragmented field and getting the leg isn’t performing exactly as universities, began conducting investithese questions answered.” expected, Hargrove can communicate gations “to efficiently solve challenges Each group at the Shirley Ryan the problem to the entire open-source associated with controlling bionic legs AbilityLab, CMU, and UT Dallas has community and make sure that his across a range of activities in the lab developed its own way to control team hasn’t made a mistake, and that


there aren’t any bugs in the code. “We can check across a couple of different groups and come to consensus that this is a high-priority problem that needs to be fixed”—or not. “You’re working with the community of developers, and that really can advance the system more quickly than if you’re doing it on your own.” Another advantage of using this system is that Hargrove’s group has been able to download the plans to make two legs—and then study control systems in bilateral amputees. “We can look at AK/AK, and we can look at AK/ BK testing,” he says. Embracing the collaborative mindset, Hargrove’s team is planning to make an algorithm available for people to use as a baseline of comparison. “We’ll program in some of the work we’ve done over the past few years, so when people design something new, they can always use that as a baseline of comparison,” he says. “We know what we’ve developed so far isn’t perfect—there’s room for improvement—so people can point that out as they develop new algorithms. And we have new ideas that we want to test out and compare with others.”

A Do-It-Yourself Approach

While the majority of research teams that have downloaded the open-source design Aaron Young, have outsourced MS, PhD actual production of the robotic prosthesis, often to companies in China, researchers at Georgia Tech have just finished building the leg in-house. Aaron Young, MS, PhD, an assistant professor in the Woodruff School of Mechanical Engineering, is spearheading the project. Young directs the Exoskeleton and Prosthetic Intelligent Controls (EPIC) Lab at Georgia Tech, which is devoted to the design and improvement of powered orthotic and prosthetic control systems. “We look at how to optimize control strategies in wearable devices for people with significant walking disability,” Young explains.

Additive Manufacturing MAKES ITS MARK ON O&P The science of additive manufacturing, or 3D printing, has come a long way since the technology made its O&P debut several years ago with the introduction of rudimentary 3D-printed hands for use with children. “The machines are maturing, becoming more reliable and more specialized,” and some are printing with newer materials that have better applications for O&P, says Jeff Erenstone, CPO, founder of Mountain Orthotic & Prosthetic Services, Create O&P, and Operation Namaste, a nonprofit that is laying the groundwork for a collaborative care network to benefit developing countries. When designing prostheses and orthoses for individuals in devel- Jeff Erenstone, oping countries as part of charitable outreach efforts, “3D printing CPO and digital design lower the barriers to entry,” says Erenstone. “They allow for more collaboration.” Here in the United States, clinicians also are embracing the technology for orthoses as well as prosthetic sockets. Brent Wright, CP, BOCO, a practitioner at EastPoint Prosthetics and Orthotics in Raleigh, North Carolina, recently switched from fused deposition modeling (FDM) to Multi Jet Fusion 3D printing, embracing newer materials to deliver definitive sockets. While the FDM materials work well for test sockets, the newer technology is durable and Brent Wright, can be leveraged “to create flexible and nonflexible areas for CP, BOCO definitive sockets, and can be used at different thicknesses—as thin as 1.75-mm thickness, making it lighter than carbon fiber,” Wright says. “We’ve had very positive feedback from patients. 3D-printed sockets change the landscape of what the socket can do. ” The Multi Jet Fusion printing at EastPoint is “outsourced” to Additive America, a new company co-owned by Wright that offers additive manufacturing services to O&P companies as well as other industries. Wright also leverages 3D printing in creating ankle-foot orthoses and pediatric upper-extremity orthoses. He notes that a lot of the add-on pieces in traditional orthoses, such as locks and springs, can be designed into a 3D-printed device, resulting in a much lighter final product. “The beauty of it is you’re only limited by your imagination,” says Wright. “But you really have to think about the final product when you’re making casts or molds.” Wright says his goal is to reach the older generation of prosthetists in order to advance 3D printing within the O&P community. “We want to work with prosthetists who have a lot of experience, who know what they want to design, and who have a lot of clinical and technical expertise,” he says. These clinicians may be able to help translate their knowledge of what patients want and what “works” well into more advanced, 3D-printed designs for optimal fit and function. “3D printing has not revolutionized O&P just yet—but it’s on the way,” adds Erenstone.




Young’s team is completing a Department of Defense project focused on creating a generalized control strategy that allows individuals with transfemoral amputation to better accomplish tasks such as navigating stairs and ramps, walking at different speeds, and engaging in community ambulation using powered prostheses. “We’re really interested in, how do we make these systems such that they’re deployable where someone could get around the community without much hassle or trouble, allowing natural transitions

and figuring out what should the powered response be to allow them to accelerate or decelerate, or sit down or turn?” Young explains. The EPIC Lab team had been conducting studies using its own version of a powered knee-ankle system. But Young believes the research will be enhanced using the open-source prosthesis. “What’s really cool about the Open-Source Leg is that several labs can use the same hardware design [but use different software], and advances in one lab would be much more translatable to the next,” he explains.

Benefits of INFORMATION SHARING Ellliott Rouse, PhD, has been a supporter of a more open approach to research and information sharing throughout his career. While a postdoctoral fellow in the Biomechatronics Group at the Massachusetts Institute of Technology (MIT) from 2012 to 2014, Rouse was involved in developing a powered knee prosthesis that uses a novel mechanism, the clutchable series-elastic actuator (CSEA)—which became the MIT CSEA Robotic Knee. The technology was so new that many people were immediately interested in learning more about it—so he decided to host a Q&A in an online forum. “In order to make the science and engineering of this, and other, projects more accessible, a friend and I did a Reddit Ask Me Anything,” Rouse recalls. “We fielded many questions related to my work here and the state-of-the-art in bionic systems; it was really rewarding to chat with people and provide some insight into the world of biomechatronics and academic engineering.” Rouse also was involved in the MIT team led by Hugh Herr, PhD, responsible for developing the custom bionic ankle prosthesis that enabled Boston Marathon bombing survivor Adrianne Haslet to dance again, after losing her leg. After Herr shared a TED Talk on the subject, Rouse and the development team published an article about the design and control of the bionic dance prosthesis in PLOS ONE, an open-format scientific journal.



Young notes the current design of the Open-Source Leg is very mechanically proficient and is less than 10 pounds, lighter than comparable systems. The design “uses some of the most advanced motors and technology so that the weight is very low but it’s also a very flexible control system for people to implement different control strategies or try to advance the state of the art,” he says. The design also integrates several advanced sensors. “It’s a very helpful testbed for research teams—more advanced than what most labs would be capable of doing themselves.” Now that EPIC Lab has built the Open-Source Leg, Young plans to transfer the controller his group had previously designed and tested on a different prototype to the new leg to continue the team’s research into control strategies. “We’ve gotten a lot of controllers, and we work with a range of transfemoral amputees, mainly K3s and K4s, and we really look at how we can optimize the device performance to study three areas,” he explains: variable speed walking, navigating stairs, and navigating ramps. The ultimate goal is to expand the capabilities and environments that individuals with amputation feel comfortable walking in. “We have a 2,000-square-foot Motion Capture Lab that has lots of forceplates embedded—in level walking, staircases, and ramps. We measure their full inverse dynamics as they’re walking around, so we can look at what their sound side is doing, with the idea that the prosthesis should be alleviating a lot of the stress on their sound side,” Young says. Georgia Tech’s control systems are being designed to alleviate much of the work being done on the sound side, so the amputated side is doing just as much

PHOTOS: Georgia Tech EPIC Lab

PhD students at Georgia Tech's EPIC Lab assemble the parts to build the Open-Source Leg entirely in-house.


mechanical work. “We formally look at biomechanics so we can re-optimize our controllers [to] get the desired mechanical outcomes we want to see in the transfemoral population.” Young also appreciates the ability to reach out to different labs and work on grants together. “The ability to collaborate is so much better, and the impact of our research in terms of when we’re publishing things—it’s a lot easier for others to emulate the research or take those findings home” and repeat or expand upon the studies. “This will accelerate the process of getting the new control technologies onto patients sooner,” says Young.

Only the Beginning

With open innovation becoming more popular across many industries as a means to speed R&D and solve problems in a more collaborative way, Rouse believes O&P will soon see more open-source research tools. Right now, researchers are the primary beneficiary of the open-source approach “because we don’t have to spend hundreds of thousands of dollars and years developing the technology,” Rouse says. But as the research stemming from use of the Open-Source Leg leads to advances in powered control of lower-limb prostheses—culminating one day in improved devices for lower-limb amputees—he predicts the field will take notice and recognize the benefits. “This first project will definitely change the field,” he says. “Other researchers will be more amenable to taking an open-source approach.” Rouse also hopes to one day see a more inclusive approach to research that involves more prosthetists and orthotists. “Clinicians have tons of ideas,” he says. “We need to connect clinicians with researchers and local engineering departments to bring it all together. This type of technology enables interdisciplinary study at a much lower barrier to entry.” Christine Umbrell is a contributing writer and editorial/production associate for O&P Almanac. Reach her at

O & P Systems, Inc.


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High-Tech and

HIGH-TOUCH The O&P master’s programs have evolved to equip the next generation of O&P professionals with tools for success


yy Students at the leading O&P master’s programs are introduced to new technologies, advanced surgical interventions, and the latest materials to ensure they are prepared to treat the O&P patients of the future. yy Instructors spend a significant amount of time on clinical skills and require many hours of patient interaction, emphasizing the “soft skills” need to become an empathetic practitioner. yy Many institutions also focus on the business side of the O&P profession, preparing students to become facility managers or owners by exploring both ethical and innovative business practices. yy O&P schools are preparing students for a value-based healthcare environment by incorporat­ing research as part of their graduation requirements, with many students completing literature reviews or capstone projects. yy Students also devote time to traditional O&P practices and learn advanced fabrication skills so they are fully prepared for residencies and careers at all types of facilities once they graduate.





program in orthotics and prosthetics at Florida International University (FIU) spend a great deal of time engaging with emerging technology. While some students are learning to manage electronic records system, others are studying advances in osseointegration techniques, and still others are becoming familiar with the latest version of CAD/CAM. The young adults often take part in sessions led by manufacturing companies designed to teach them how to use the latest O&P technologies. “We make a lot of time to learn” about the latest innovations that may benefit O&P consumers, says Arlene Gillis, CP, LPO, director of the FIU master’s program. “Almost every day [students] are using a new technology.” Graduates take their well-honed technical skills with them once they complete their degrees and become residents, then later secure clinical positions. Often, the recent graduates are called on to educate more seasoned practitioners at their new facilities on these advanced technologies, says Gillis.

Training Tomorrow’s Leaders

PHOTO: Mark Muller, CPO, FAAOP, California State University Dominguez Hills

FIU isn’t the only graduate program sharing the latest advances with its students. Many of the leading O&P master’s programs focus heavily on cutting-edge technologies—but they also prioritize research, the soft skills needed to become a well-rounded clinician, best business practices, fabrication, and many other areas of importance for future practitioners.

Arlene Gillis, CP, LPO

With advances in O&P componentry occurring at an everincreasing rate, technology is a key focus at all of the schools. The O&P program at University of Texas (UT) Southwestern, for example, has a firstyear class in its curriculum focused specifically on new technology. The evolving curriculum ensures all students become familiar with advances. “We continually introduce the latest and greatest,” says Leslie Gray, CPO, LPO, program director. Recent additions to the curriculum include an expert lecture on upperextremity prosthetic neurointegration, custom-fabricated prepreg carbon orthoses, and an introduction to advanced prosthetic designs. “We bring in guests and manufacturers,” with an ever-evolving list of invitees, and the course syllabus is updated each year with new topics and fresh areas of focus.

Leslie Gray, CPO, LPO

Mark Muller, CPO, FAAOP, department chair of orthotics and prosthetics at California State University Dominguez Hills (CSUDH), says the O&P master’s program there encourages students to become familiar with

Students at California State University Dominguez Hills study innovative business practices—and can choose to pursue a veterinary certif­i cate for animal care in O&P. O&P innovations. “They are learning the newest technologies and getting a taste of the older skills,” Muller says. Among the “new technologies” students explore at CSUDH is additive manufacturing for both low-end and high-end devices. “The need to learn more about scanning options available, how to implement CAD design to create more intuitive devices, and the various options for additive manufacturing” are areas of focus, according to Muller. CSUDH students also learn about new surgical techniques, like the various options for osseointegration, implantable biomedical devices, agonist/antagonist myoneural interface techniques to boost proprioception among amputees, and neuromusculoskeletal electrodes. In addition, CSUDH professors teach some of the latest fabrication techniques utilizing prepreg carbon and rolled high-consistency rubber silicones for custom and innovative O&P devices, “where you can implant sensors, create feedback loops, and embed electronics, monitors, hepatic controls,” says Muller. This type of education “allows students to create

Mark Muller, CPO, FAAOP

devices that will truly help justify the devices we create, to better serve the individuals that require our services.”

Clinical and Business Training

Preparing students to fit patients with both traditional and high-tech O&P devices using the latest fabrication techniques is important—but so, too, is developing young practitioners’ clinical skills, by teaching interviewing techniques, empathetic responses, and counseling practices. At the Northwestern University Prosthetics-Orthotics Center (NUPOC), “we are blending in what I call ‘soft skills,’” explains J. Chad Duncan, PhD, CRC, CPO, NUPOC director. “We are always reinforcing [people/communication skills] and giving feedback to the students …. We are really working on those skills of being person-centered, patient-centric.” O&P ALMANAC | SEPTEMBER 2019


Proposed Legislation Would Expand O&P Schools AOPA is working closely with Congress on TAKE ACTION the recently introduced Wounded Warrior Workforce Enhancement Act (WWWEA), AOPA needs your help to get support HR 2487 in the House and S 1315 in the for this important legislation. Write your Senate, which would authorize $5 million representative and senators and ask per year for three years to provide limited, them to co-sponsor the WWWEA. Visit one-time competitive grants to qualified https://aopa.freeenterpriseaction. universities to create or expand accredited com/Xlm00yT to send a message to advanced education programs in O&P. Over the past decade, the medical members of Congress. Contact Justin conditions faced by a growing veteran Beland, AOPA’s director of government population have become more complex. affairs, at for Despite an increasing demand for clinimore information. cians, in part to meet the needs of veterans living with limb loss and limb impairment, 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. With a significant percentage of the nation’s trained and experienced O&P clinicians eligible 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 the aging population and veterans. WWWEA would create grants to help universities establish master’s degree programs in O&P or to expand upon existing master’s programs. This legislation would ultimately allow for more effective treatment of patients in the U.S. Department of Veterans Administration (VA), Medicare, and Medicaid programs, and result in fewer co-morbidities and a reduction in costs, according to AOPA. It 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.



At Alabama State University, students also are immersed in soft skills-related training, says Scott Bretl, CPO, program director and chair of the department of prosthetics and orthotics. Instructors often share personal experiences and offer suggestions regarding how to be a good colleague and work well with diverse populations. “We always try to infuse our teaching with personal anecdotes about what promotes respect in the workplace,” says Bretl. Some O&P programs even pair interpersonal skills with education about billing and electronic record systems. “You have to be smart on the business side, so you can continue

Expanding the O&P Research Well Given the movement toward value-based care and the desire to offer evidence to payors and referral sources that O&P intervention is improving quality of life for patients, the O&P schools are incorporating research as part of their graduation requirements. Educators find it increasingly important that students become clinicians who advance research. At NUPOC, students have been dedicating a year to working on a structured literature review, and Duncan hopes that future students will take this focus one step further. “We will be moving to case studies and involving students in past cases and allowing them to work through this process,” he says. “A lot of single cases have been identified out in the field, but people don’t have time to get them published. The students will … be an assistance to the field” in enhancing O&P research efforts.

PHOTO: Getty Images

Research has shown that empathetic clinicians tend to have better outcomes, which is one reason why NUPOC focuses on it, according to Duncan, who has a background in counseling. When done correctly, taking an empathetic approach “can be very, very successful,” he says. CSUDH also prepares students to interact with O&P consumers, offering its students 600 hours with patients prior to graduation. “We spend so much more time on basic skills … interviewing skills, how to talk to patients and other individuals,” Muller says. “Students are going to work with real patients, and we put them in environments to succeed.”

to take care of other people,” Gray says. “Yes, most people don’t like the business and billing stuff we do. But it is about making education as realistic as we can.” FIU instructors strive to ensure their students understand how to run a business ethically. “Our primary focus is to create a well-balanced practitioner, to have a good balance of the clinical, ethical, and fabrication,” Gillis says. And some of the schools teach innovation in O&P business practices—or how to set O&P facilities apart by offering unique services. CSUDH, for example, encourages students to expand their ideas about business models. One way they’re doing that is by teaching veterinary prosthetics and orthotics. “We are doing a veterinary certificate for animal care in O&P,” Muller says. “I have been working with animal prosthetics and orthotics, and there is a big void …. The fits have been terrible, and I see the animals suffer.” The program has been a big hit with students. “They get so excited about a [different] business model—not just classic orthotics and prosthetics,” he says. “They love it.”

institutional review board, so they can pursue a variety of projects, Gillis adds. Student research doesn’t just help them become better clinicians; it also helps them advance the field. “As a profession, we have not been able to lead our research in the past,” Gillis says. “It is very beneficial to have trained clinicians who know how to do research.”

Fabrication Focus


O&P students at Florida International University experiment with 3D image capturing systems. At Baylor University, most students pursue a traditional research thesis project. “They are going to work one-on-one with a mentor and work specifically with protocols” and eventually submit the project for publication, says Jared Howell, CPO, LPO, director of orthotics and prosthetics and director of the Center for O&P Clinical Innovation. A few students each year opt to create a new product or device, rather than complete a thesis, which always yields interesting inventions. Students at Alabama State University take four research courses that culminate with a capstone project “that leads students toward developing and completing a research project that obtains results and potentially demonstrates trends worthy of sharing at national meetings,” Bretl says. At CSUDH, students spend a yearand-a-half on research “that is part of a capstone requirement.” It’s structured so students can take the project with them if they pursue a doctorate or decide to try for a grant to publish. “We’re giving them a pathway to feed into rehabilitation or an engineering science PhD,” Muller says. “If they want to learn to be an inventor or learn 44


about intellectual property and patent design, they can take this further.” Students at UT Southwestern will now have more options when it comes to research, as they can pair with mentors in doctorial programs for applied clinical research. “We really want the research to be of value to the profession,” Gray says.

Scott Bretl, CPO

Some FIU students have been positioning their research to make technology more accessible. To describe those efforts, Gillis provides an example of a gait analysis device on the market that costs about $20,000. Small businesses can’t afford that—but they would benefit from having access to gait analysis for their patients. Students might try to design an affordable device to assess gait that will help these small businesses prove outcomes. “It helps prove efficacy to come up with an inexpensive tool that practitioners can use in the office,” Gillis explains. FIU students also have access to an

Students who are well-versed in research and advanced technologies will be well-prepared to help move facilities forward once they land clinical positions. But it’s also important that they invest time and effort into learning traditional O&P fabrication techniques. Howell says fabrication remains important at Baylor, and instructors emphasize that students should have strong hand skills to succeed in the field. At FIU, “we spend a lot of time doing fabrication,” says Gillis. “Students understand what happens when they send a cast or an image to the central fabrication, and they are very aware of giving directions. They will eventually be clinicians or business owners and managers, and they need to understand how to explain it to make it work.” Gillis says FIU students visit fabrication centers and talk to those crafting the devices. That way they get a complete understanding of how incomplete casts or poorly worded directions can impact the quality of device, she adds. The curriculum at Alabama State University also includes fabrication, as many of the O&P program’s graduates work in small rural practices and end up doing more technical work than might be required in urban or academic facilities. “We try to meet and surpass the fabrication curriculum requirements for all courses to give our students dynamic exposure,” Bretl says. “We recognize the importance of generating students who at least have the fabrication experience to know what they are asking for when they delegate or outsource this work.”

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At NUPOC, “we are really focused on capturing casts and impressions, so they can describe what they are doing,” says Duncan. “They will evaluate their cast … and we discuss what is right or if they should take another.” This practice of assessing the quality of their casts helps students when they become clinicians. “They are a little bit more knowledgeable that the device is meeting the needs of their patients,” Duncan explains. Muller says CSUDH also highlights fabrication skills. “We are still [hearing] a lot of concerns from owners of facilities that students aren’t coming adequately prepared in the technical areas,” he explains. “Our students get enough time with hand skills … we teach leather

working and metal working, and different fabrication and sewing, and they see how it is done.” UT Southwestern recently introduced an elective course in the fabrication lab, which is wildly popular with students, says Gray. “They work as a technician in our fabrication lab, and they do that for a semester to increase their hand skills. It has been so successful that almost every student takes that course.”

Ready for Residencies

All of the O&P master’s programs prepare students to succeed as O&P residents—but one school takes a unique approach to the residency requirement. Baylor’s program integrates residency into its core program, rather

Fate of the Georgia Tech O&P Master’s Program Unknown



Taking That Next Step

Students in today’s O&P master’s programs have a lot to accomplish during their graduate programs. From learning basic O&P curriculum and fabrication techniques, to becoming familiar with the latest technological advances, to studying clinical skills, to hearing about successful business practices, to embarking on their own research projects—there is much to do as an O&P master’s student. Fortunately, the O&P schools are looking to what will be needed in the future and offering the appropriate classwork and programs to ensure today’s students will be tomorrow’s top clinicians. Meghan Holohan is a contributing writer to O&P Almanac.

PHOTO: Getty Images

In May 2018, faculty at Georgia Institute of Technology’s O&P master’s program were surprised when a dean nixed the program during a reorganization. The dean informed staff they could no longer accept students for fall of 2018, and the school’s last class of O&P students graduated in May 2019. Only two faculty members remain, and they’re struggling to keep the program afloat. “We are such a small profession, and higher education is going through some real challenges,” says Geza Kogler, PhD, CO, program director and director of the Clinical Biomechanics Lab. “If there is a small program, taking up lots of resources and lots of space, we’re the first one to go.” While the president of the university has until May 2020 to make a decision about reactivating or terminating the program, the dean who shuttered the program resigned, and the interim dean is hesitant to make lasting decisions before a successor arrives. What’s more, the president of the university is newly hired. “That really complicates our ability to preserve the program,” Kogler says. Kogler has talked with representatives from Kennesaw State Geza Kogler, University and the Medical College of Georgia at the University of PhD, CO Augusta about potentially moving the O&P master’s program to one of those institutions. While both universities seem receptive to the idea, transferring the program could be slow going. “They are deeply interested. But it takes a long time,” he explains. “The problem is, there are budgets that have been established for a year.” And, he worries that what happened at Georgia Tech could happen at other universities: “Every program is vulnerable.”

than preparing students for a residency once coursework is complete. During a 36-month timespan, Baylor students fulfill their classroom work, research requirements, and 18 months of dual residency clinical curriculum. The program sends graduate students to curated residencies, which help them develop a wide range of skills. “We make sure that every student gets a pediatric experience and an institutional experience,” Howell explains. “We send students to places where they wouldn’t normally do a rotation.” Most of the students complete an international residency, and many of them do a rotation in practices outside of Houston. But this encompassing residency experience doesn’t occur until after the first year, which involves 40 hours a week of classroom, research, and fabrication experience. “There is some background that occurs in the first year. Students see patients, they work through the process, they learn how to do a physical exam and tech care, and learn biomechanics,” Howell says. “It’s intense, and we keep them going pretty hard most of the day, and many evenings they are studying. It is pretty rigorous, but they thrive.”

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Hear the latest cutting-edge O&P research and best business practices during the Thranhardt and Hamontree Award sessions at the 2019 National Assembly





most innovative O&P thinkers are recognized by AOPA when they are invited to give presentations at the annual National Assembly. This year, conference-goers will be treated to five feature presentations in September—two by Thranhardt award winners, recognized for their important research studies, and three by Hamontree nominees, selected for their innovative business strategies. This year’s Thranhardt presentations will offer the latest clinical information, with honorees sharing the results of their in-depth research endeavors—one focusing on cranial orthoses and the other on an innovative approach to use health economic instruments in the O&P facility. In addition, the Hamontree session will introduce numerous innovative ideas and “best” business practices—focusing on meeting the requirements for medical necessity, simple strategies for containing costs, and a practice approach to implementing an O&P quality management program.

Thranhardt Awards

The 2019 Thranhardt presentations will feature the latest of SHOW clinical information, with honorees presenting the results of their in-depth research endeavors—one by Tiffany Graham, MSPO, CPO, LPO, FAAOP, and Kelly Millay, MPO, focusing on orthotic treatment of asymmetrical brachycephaly, and the other by Andreas Hahn, MSc, PhD, exploring the innovative use of health economic instruments at O&P facilities. These forward-thinkers will share their findings beginning at 8:30 a.m. on Thursday, September 26. The Thranhardt Awards were established in 1996 by a gift from J.E. Hanger in memory of Howard R. Thranhardt, CP, and the winners “represent the best in orthotic and prosthetic patient care,” according to AOPA President Jim Weber.


NEED TO KNOW • The presentation of Thranhardt and Hamontree Awards during the 2019 AOPA National Assembly provides an opportunity for San Diego conference attendees to gain exposure to high-level clinical and business presentations. • The two 2019 honorees of the Thranhardt Award will give their award-winning presentations on Thursday, September 26, during the General Session that begins at 8:30 a.m. • Three O&P professionals have been nominated for the Sam E. Hamontree, CP(E), Business Education Award, and will present papers on Friday, September 27, at 1 p.m. • The Hamontree contenders will share best business practices in meeting the requirements for medical necessity, simple strategies for containing costs, and a practice approach to implementing an O&P quality management program.

Tiffany Graham, MSPO, CPO, LPO, FAAOP

Significant Factors in Orthotic Treatment of Asymmetrical Brachycephaly

Tiffany Graham, MSPO, CPO, LPO, FAAOP, and Kelly Millay, MPO Graham’s research in cranial remolding treatment has earned her two Thranhardt awards in two years. Last year’s presentation looked into the effectiveness of cranial remolding orthoses in infants with deformational plagiocephaly; this year, Graham reports on infants with asymmetrical brachycephaly, which involves both diagonal asymmetry and flattening in the back of the head. Graham undertook both studies, and a third is in progress, in hopes of improving outcomes data for insurers and providing more information to clinicians as they treat these cases. She and fellow researcher Millay, a former graduate student of Graham, sought to determine which presenting factors have the most influence on the success of achieving correction. Graham and her graduate students at University of Texas Southwestern Medical Center conducted a retrospective chart review of 2,104 patients treated at Level 4 Prosthetics and Orthotics (now Restore Prosthetics Orthotics Cranial) in Texas, which yielded 500 patients with a cephalic index, or CI (width-to-length ratio), equal to or above 90 percent and a cranial vault asymmetry index, or CVAI, equal to or greater than 3.5. “Both numbers classified infants’ head shapes as not within normal limits,” explains Graham. “We had a range of mild, moderate, severe, and very severe deformation.”

• One O&P professional will be honored with a Lifetime Achievement Award, and three others will receive Legislative Advocacy Awards. In addition, the Otto and Lucille Becker Award will be presented for the best orthotic abstract and the Edwin and Kathryn Arbogast Award for the best prosthetic abstract submitted by a student or resident. O&P ALMANAC | SEPTEMBER 2019


The study defined correction as a final CI equal to or below 90 and a CVAI less than or equal to 6.25, which correspond to typical treatment goals of orthotists. Graham and Millay found that the age treatment was initiated and the severity of the cephalic index were the most important factors in predicting successful treatment. The conclusions are similar to those of the 2018 study in that age played a factor in both groups for predicting successful treatment. This year’s research showed CI to have a strong effect; last year’s study found CVAI to have a strong effect. In addition, the 2019 study found that prematurity, when age corrected, and torticollis, when treated at the same time, did not affect the final head shape of infants in the population in this study treated with cranial remolding orthoses. “Since the CI and age are driving factors, the younger we can treat these kids, the better,” says Graham. “We want to treat them before the CI gets severe. A lot of studies look at treatment before or after six months, but we are finding that earlier treatment, after three months, means better results.” Graham and her associates have begun their third and final study in this area, which will look at brachycephaly without asymmetry. “My hope is that when all three studies are completed, we can take a more in-depth look at the differences among them,” says Graham. In addition to presenting her award-winning research at the National Assembly, Graham will present a free paper and a poster related to her asymmetrical brachycephaly study.



Andreas Hahn, MSc, PhD

Hamontree Awards

This year’s Hamontree presentations, scheduled for Friday, BUSINESS ABSTRACT September 27, beginning at 1 p.m., were established in 2010 to honor Sam E. Hamontree, CP(E), by recognizing innovative business ideas. Andreas Kannenberg, MD (GER), PhD, will lead off with a discussion of medical necessity, followed by Mark Ford, whose presentation focuses on profitability. Karyn Kessler, CHPC, CHC, will close the session with a lecture on developing quality management programs.


The Use of Health Economic Instruments To Evaluate Prosthetic Services: Experience With Over 400 Patients in Germany and India

Andreas Hahn, MSc, PhD In this research, Hahn reviewed more than 400 patients in Germany and India to evaluate prosthetic use and its effect on the health status of particular groups. “Health economic thinking tries to quantify the value of the health state,” he explains. “We use the concept of quality-adjusted life years, or QALY, and health utility numbers, with 1 being perfect health and 0 being death, to evaluate the value of a health condition in different societies.” One insight Hahn will share is the challenges associated with using realworld data compared to conclusions resulting from controlled studies. “Using real-world data, we are faced with a wide heterogeneity of components being used and health states being analyzed,” he explains. “Often we deal with a combined effect, so it is difficult to isolate one component.” Hahn’s study concluded that amputees who are less mobile are those who will benefit the most from advanced prostheses. “Our common behavior is that we think more sophisticated prosthetic components should be used with patients who have the most mobility,” he says. “And advanced devices for those with higher mobility were cost-effective, but we very consistently saw that low-mobility patients profited even more.” Hahn suggests that, in the future, reviewing certain subgroups could yield more insights into the relevance of mobility ratings and other information about the value provided by specific prosthetic components.

Andreas Kannenberg, MD (GER), PhD

The Concept of Medical Necessity: How To Read and Play the Game

Andreas Kannenberg, MD (GER), PhD The concept of medical necessity is important from a clinical standpoint, of course, but it has an enormous impact on reimbursement, says Kannenberg. “Medicare and private insurers evaluate medical necessity to decide on claim applications,” he notes. “If you can check all the boxes, it will have a big influence on your approval rates and timelines. If not, you are more likely to be rejected and have to appeal, which takes longer and may not ultimately succeed.” Physicians and clinicians must explain why the patient needs a particular device and why another, less sophisticated, less expensive alternative will not meet the patient’s medical needs.

“Many clinicians will present evidence that the device is better than others—‘You can climb a mountain in this knee’—but is the patient in the habit of climbing mountains?” asks Kannenberg. Clinicians must start with the needs of the patient and then argue about the proven benefits of a device to meet them. He gives an example of the microprocessor-controlled C-leg. “Studies show that when patients use a C-leg, they fall significantly less often than when using nonmicroprocessor knees. But if you have a patient with no history of falling, it’s not a strong argument,” he explains. “If you have a patient using another knee and she falls at a certain regularity, that’s a good argument. And you can back it up with studies showing that the C-leg reduces falls by up to 80 percent, reducing the risk of sustaining injury.” Kannenberg’s approach to using the concept of medical necessity includes three components. First: Is there an unmet patient need? “If the patient’s needs are being met, the discussion can stop right there,” he says. Second: How

does the preferred device meet those needs? How is it better than alternative devices in meeting patient needs? Third: How does clinical evidence support the argument for using this device? Taking this three-pronged approach, he says, will result in more timely claim approvals and improved patient care.

Mark Ford

The Hidden Drain on Practice Profitability

Mark Ford Managing costs is an essential component of profitability, says Ford, an O&P consultant. For most O&P practices, the largest cost is for goods, second only to that of employees. To avoid excessive spending on

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goods, step one is to assess actual spending numbers and then use an industry benchmark to assess that number. “The easiest benchmark to access is the AOPA Operating Performance Report,” says Ford. “Find out where you are today. How are you tracking it? Where do you stand vis-à-vis the industry?” Use whatever tools your facility has, he recommends. From a simple spreadsheet to sophisticated purchasing system software, your facility can consolidate information and manage it. Then—once you have the initial data— set targets on how to improve. “For example,” Ford explains, “I have seen hundreds of O&P facilities in my career, and it is scary how much inventory is just sitting on the shelf. I’ve done audits for facilities with unreturned inventory that accounted for hundreds of thousands of dollars.” To address this issue, facilities should put a system and process in place to properly manage inventory, then communicate that information to everyone on staff.


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Another drain on profitability is failing to work out—or communicate— discounts and pricing arrangements with suppliers, says Ford. “Are practices highlighting over and over again that they have preferred suppliers? “You don’t need to be a computer whiz to gather and assess this information,” Ford says. “Whether you have an online purchasing system or manual lists, you can identify and halt practices that reduce your profitability.”

Special Recognition

In addition to the Thranhardt and Hamontree Awards, several individuals will be recognized for their contributions to the O&P profession during the AOPA National Assembly in San Diego.

Lifetime Achievement Award

Jim Kaiser, CP, LP

Karyn Kessler, CHPC, CHC

Quality Management Program Development in O&P

Karyn Kessler, CHPC, CHC According to Kessler, O&P businesses do not need to choose between increasing revenue and providing high-quality patient care. The way to improve revenue is by improving care, and developing a quality management program is a tool to accomplish both. “A quality management program focuses on the patient,” says Kessler, who is vice president of compliance, chief privacy officer, Hanger Inc. “Revenue is not part of the quality mindset. But if you do the right thing for patients, revenue will follow.” The quality management program Kessler developed for Hanger 15 years ago is designed for a large and diverse O&P organization. But the program is scalable from small to large businesses. You can start small, using the same strategies, she says. Kessler advises identifying and measuring factors that affect the quality of care, including such issues as complaints, patient satisfaction, outcomes, device turnaround time, and clinicians’ skill sets. Once the facility identifies an area with problems— for example by reviewing patient complaints—managers should seek out the root causes. “Is it scheduling? Service? Clinical? Wait times?” she 52


Each year, AOPA presents the Lifetime Achievement Award, bestowed on individuals who have made significant contributions to the O&P field. The AOPA Board of Directors has named Jim Kaiser, CP, LP, as the recipient of the 2019 Lifetime Achievement Award.

Ralph R. “Ronney” Snell, CPO, FAAOP, Legislative Advocacy Award

Maynard Carkhuff

Stella Seiber Glenn Crumpton, CPO, LPO, CPed

This award recognizes individuals who have made valuable contributions toward advancing the legislative and regulatory goals of the O&P field by motivating members of Congress and other decision makers to take action on behalf of O&P. The 2019 award winners are Maynard Carkhuff, Stella Sieber, and Glenn Crumpton, CPO, LPO, CPed.

Student Poster Awards

The Edwin and Kathryn Arbogast Award and the Otto and Lucille Becker Award will honor two meritorious scientific papers submitted for presentation as a poster at the 2019 AOPA National Assembly by a student or resident. The purpose of these awards is to encourage students and residents to share their research through outstanding poster presentations. This year’s winner for the Arbogast Award, sponsored by WillowWood, is Charles Noble from the University of Pittsburgh, for his submission, “Is the Allied Health Field ‘Passing the Buck’ Regarding Fall Training?” The 2019 winner of the Becker Award, sponsored by Becker, will be presented to Erin McGraw of the University of Pittsburgh for her presentation, “Comparing the Comfort of Ankle-Foot Orthosis Designs: Sleeve Cover Versus Traditional Cuff Strap.” asks. Once the cause is identified, the facility can take corrective action. This approach works for both patient-care facilities and distribution companies. “If you measure delivery time, your out-of-stocks, and complaints, these are all things that affect patient care that are sometimes left out of the equation,” she notes. Kessler stresses that building a successful quality management

program requires full commitment from the entire organization. “It takes patience to build the program and full support from the top down,” she says. “The program is easy to get going, but it needs commitment to keep it going.” Deborah Conn is a contributing writer to O&P Almanac. Reach her at


Leveraging Robotics for O&P Solutions Josh Caputo, PhD, founded an R&D company as a spinoff of his doctorial work at Carnegie Mellon University

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.


OSH CAPUTO, PhD, SAYS a love of

robotics is in his DNA. Always interested in solving challenging problems, he was drawn to the field of orthotics and prosthetics when he was considering his next move after earning bachelor’s degrees in mechanical engineering and electrical and computer engineering at Carnegie Mellon University (CMU). “I was looking at PhD programs, having never really thought about the world of O&P, and then I met my future thesis advisor, who was founding a lab focused on developing robotic exoskeleton and prosthetics technology,” recalls Caputo. “I immediately thought, ‘Oh, wow, this is cool! I can work on some really hard and exciting technical problems,



Research and New Technologies

The Experimental Biomechatronics Laboratory and the greater Pittsburgh area provided the perfect environment for Caputo to combine his interest in problem-solving with the complex world of O&P. “The main body of my research involved developing a robotic anklefoot prosthesis testbed, which was the forerunner to what we now call the Caplex system,” Caputo says. “The testbed was designed to explore the effects of prosthesis design on the mechanics of gait.” Caputo completed his doctoral thesis based on the development of this system and a series of experiments that focused on informing ankle-foot prosthesis design and prescription through systematic experimentation. His work at the lab led to his decision four years ago to found his own company, Humotech (Human Motion Laboratories LLC), headquartered in Pittsburgh. Caputo

PHOTO: Josh Caputo, PhD

Josh Caputo, PhD, founded a company in Pittsburgh after earning his bachelor and doctorate degrees from Carnegie Mellon University.

while at the same time doing work that benefits a vulnerable population.’” Given that epiphany, Caputo decided to pursue his PhD in mechanical engineering at CMU. He subsequently spent countless hours with his thesis advisor, Steve Collins, PhD, who has since relocated to Stanford University.


serves as the company’s president and chief executive officer. “We began as a CMU spinoff in 2015, and we’ve continued to develop and expand on the ideas I began exploring in my doctoral work at CMU's Experimental Biomechatronics Laboratory,” he notes. These days at Humotech, Caputo is focused on further developing the Caplex system, including prosthetic and orthotic (or exoskeleton) variants, and applying it to solve real-world problems—now, as a tool to accelerate research in various laboratories around the country and, soon, as a tool to gather evidence to inform prescription and reimbursement. Caplex is a “robotic, wearable device that we program to mimic the behavior of conventional devices or to test novel device ideas,” explains Caputo. For prosthetics, the technology is worn like a conventional device; for prosthetic foot testing, the emulator attaches to the user’s residual limb with a standard pylon. “What makes it very different from other devices is that the

system is powered and controlled by an offboard actuator,” says Caputo. The company strives to help scientists and technologists improve the research and development process, so that it is more productive and more efficient, and results in products and solutions that are highly relevant to what people need. According to Caputo, “Our approach is very collaborative. Given how challenging this work is, we feel that is essential.” Caputo and his team have been working with researchers at the U.S. Department of Veterans Affairs and the U.S. Department of Defense in testing the prosthetic foot emulator. These studies are testing the effectiveness of the Caplex system in improving the process of prescribing prosthetic feet by using the system to quickly and easily “test drive” prostheses with different characteristics, resulting in better mobility for lower-limb amputees. The Caplex system enables the researcher “to collect highly individualized outcomes data quickly in the clinic,

to immediately inform the prescription and reimbursement of the care of that patient. We see it as a complete paradigm shift as far as outcomes research is concerned,” he says.

Moving Forward

Caputo has several other O&P-related projects in the works. “My work continues to be focused on developing tools and systems that enable researchers— and, in the future, clinicians—to explore the important questions that interest them, so that instead of spending their time building parts and prototypes, they can focus their time on deepening their understanding of how to best assist the users of orthotic and prosthetic devices,” he says. “Ultimately, that leads to innovative breakthroughs and better outcomes for everyone. That’s true for the whole range of research interests—from foundational biomechanics research to the development of next-generation assistive devices to solving the challenges clinicians and patients face day to day.”






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Caputo’s team at Humotech is focused on developing tools and systems that enable researchers—and, in the future, clinicians—to explore the important questions that interest them.



everyone we work with. We also work with local O&P clinicians who provide clinical care every day, to make sure that the work we do is grounded in reality. The ultimate goal of all of this work is to improve outcomes for patients. We’re all in this together. Together we can push the field forward.”

Accelerating Innovation

Although Caputo loves spending time “building things,” he also recognizes that O&P stakeholders must think about the big picture— how O&P processes, systems, organizations, and policies are working (or not). It’s through this thinking that he came to focus on streamlining the technology development process as a means to accelerating innovation in the O&P field. “What we’re trying to do—it's going to take an academic generation or two to play out— because we’re changing

Notable Works Josh Caputo, PhD, has contributed several publications to the scientific community. Some of his most impactful works include the following: • Caputo, J.M., and Collins, S.H. “A Universal AnkleFoot Prosthesis Emulator for Experiments During Human Locomotion.” Journal of Biomechanical Engineering 2014; 136(035002):1-10. • Quesada, R.E., Caputo, J.M., Collins, S.H. “Increasing Ankle Push-Off Work With a Powered Prosthesis Does Not Necessarily Reduce Metabolic Rate for Transtibial Amputees.” Journal of Biomechanics 2016; 49:3452-3459. • Malcolm, P., Quesada, R.E., Caputo, J.M., Collins, S.H. “The Influence of Push-Off Timing in a Robotic Ankle-Foot Prosthesis on the Energetics and Mechanics of Walking.” Journal of Neuroengineering and Rehabilitation 2015; 12(21):1-14.

PHOTO: Josh Caputo, PhD

Since his early days in the Experimental Biomechatronics Laboratory at CMU, Caputo feels like he is constantly learning. “O&P is very complex,” he says. “We know that there is a big need to improve quality of life for patients and reduce healthcare costs. Behind every observation is a myriad of causes that are really hard to test and understand. Even just formulating questions is hard, let alone answering them. This uncertainty creates friction among stakeholders. This all makes it hard for discoveries and innovation to impact patients. Great ideas get stuck. Every question in O&P seems urgent. My focus is: How can we help to reduce complexity? And how can we better position patients as the drivers of innovation?” Caputo is committed to a collaborative approach to research and works with others to advance the technology he has created. Collaboration “benefits everyone involved,” he explains. “We provide a powerful system that aids researchers in their work; their feedback helps guide us toward new offerings and ideas that benefit their research even more. “The same is true with the clinical research; what we learn from patients leads to improvements for us and

the expectations of what’s possible to accomplish within the timespan of a student’s project or career.” He believes there are exciting possibilities for the next generation of clinicians. “One of my goals is to make this research more accessible. Because of the need, traditionally, to build hardware and software from scratch, folks wanting to get involved in this research needed to have all sorts of resources and personnel, knowledge, and experience. Typically, you had to be a highly skilled engineer who’s developed a pipeline of highly successful research funding. This excludes a lot of folks who might get involved.” Caputo believes that by providing common tools, he can help give people a running start. “With our system, it’s now possible for an O&P clinician, even a student, to explore tradeoffs in prosthetic or orthotic device design and test different approaches to assisting patients, whether it’s for a research project or in their clinic. To me, this looks like real-world evidence-based medicine.” As Caputo continues to leverage his love for robotics to advance technologies for the O&P community, there will be benefits for patients and clinicians alike.




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Liston Prosthetics


Open for Business Utah clinician resumes his role as an O&P business owner





Jim Liston, CP, opened the doors to his new facility just three months ago.

Liston Prosthetics

Jim Liston, CP

FACILITY: Liston Prosthetics OWNER: Jim Liston, CP LOCATION: Murray, Utah HISTORY: Three months

addition to using some central fabrication services. Liston is not employing 3D printing yet, although he believes it may have a role to play in O&P in the future. “Right now, I think it solves more of a fabrication issue than a fit issue, so it’s not really helping me provide better patient care,” he says. He has been working closely with his wife, Melanie, and daughter, Brenna, who both work for the company, in seeking accreditation, getting a Medicare number, and setting up agreements with Medicaid and private insurance companies. This time around, owning his own O&P facility is “more fun—and much easier,” Liston says. “I know how the industry works, and I’m more at peace with the uncertainty. Technology makes everything easier—even for the credentialing process.” Liston embraces technology within the practice as well, using O&P office management software and computers and tablets to create a paperless

office. “It takes upfront training and time,” he says, “but I think it will be much more efficient.” Liston is starting over with referral sources, many of whom are familiar. “Once they know I’m back in business, I expect them to send over patients,” he says. His marketing strategy focuses on word of mouth, from both referrers and patients. “When I started my first business, it took presence at a clinic over time for physicians to see their patients doing well and to gain trust in me as the clinician,” he says. “Experience and reputation—that’s what it takes to get follow-up referrals.” Because Liston is focused on the immediate future in his new business, he has few long-term plans at this point. He wants to get his facility up and running, maintaining it as a small operation that is patient-centric. “I’m excited and re-energized by this process. I love it!” Liston says. “I got into this business to make a difference in people’s lives, not to focus on revenue goals or number of patients. I can take the time I need to take care of people, and as long as I can keep the door open and the lights on, I’ll be happy.” Deborah Conn is a contributing writer to O&P Almanac. Reach her at

PHOTOS: Liston Prosthetics

Liston Prosthetics in June of this year, Jim Liston, CP, is right back where he wants to be. After nearly 30 years as a practitioner, “I’ve come full circle,” he says. Liston established his first O&P facility in 1994, in Murray, Utah, and in 2007 became the first facility owner in the state to sell to a large, national O&P chain. Liston continued to work at his former facility for a decade, where, he says, “I eventually found myself with seven offices, playing much more of an administrative role and spending far less time with patients.” He found himself missing patient interactions. “I got into this business to take care of people,” Liston explains. “I finally decided to start up again as a sole practitioner. I waited out a twoyear noncompete agreement, and we opened our doors in June.” As it turned out, Liston was able to return to his original facility, which he owned and had leased to his employer for 12 years. The 3,600-square-foot space in a professional office building features five patient rooms, a gait room with parallel bars, and large hallways that accommodate gait evaluations and device alignment. “We also have a large amount of space around the building with a variety of terrain, so there are endless possibilities to navigate challenging surfaces,” he says. Liston collaborates with other clinicians on upper-extremity devices, but his real passion is lower-extremity prosthetics. He makes and adjusts prostheses in an in-house fabrication lab in

BOC HELPS YOU get back to what matters

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Steeper Group


Gaining Momentum

International manufacturing firm offers updated O&P solutions


N 1918, HUGH STEEPER began



Product research and development using CAD/CAM technology

COMPANY: Steeper Group OWNERS: Paul Steeper and John Midgley LOCATION: Leeds, United Kingdom, and San Antonio, Texas HISTORY: 98 years

Paul Steeper (right) with business partner John Midgley (left)

SteeperUSA offices, San Antonio

Instead, the company sold one of its products, the Bebionic hand, to Ottobock, and Paul Steeper and business partner John Midgley, who currently serves as chief financial officer, acquired the remainder of the firm in 2017. “Post-flood we moved into a new 60,000-square-foot purpose-built facility in Leeds, housing all our central operations, and have really gathered momentum since. We now have over 400 staff across the business, of which 45 percent are CPOs and technicians, based in numerous clinical facilities across the United Kingdom,” Steeper says. In 2010, SteeperUSA was formed in San Antonio, focusing on the supply of upper-extremity prosthetic components and silicone cosmetic products. SteeperUSA offers body-powered components, lightweight cosmetic systems, PVC and silicone cosmetic gloves, and its Skinergy Plus below-knee cosmesis. The company also has developed a customized silicone that uses a digital color-matching system called Spectromatch, available to clients worldwide.

Deborah Conn is a contributing writer to O&P Almanac. Reach her at

PHOTOS: Steeper Group

providing upper-extremity prostheses to soldiers from World War I, hand-crafting devices from wood, metal, and leather and assembling them to fit each patient. That led to the 1921 formation of Hugh Steeper Ltd., based within the campus at Queen Mary’s Hospital, Roehampton, in London. The company grew steadily, later serving World War II amputees. When Britain’s National Health Service formed in 1948 and began issuing patient-care contracts, Hugh Steeper Ltd. began providing fabrication and fitting services nationwide. Steeper entered export markets from the early 1960s and today supplies upper-extremity devices to O&P facilities worldwide via a global network of distributors. The company continues to provide prosthetic and orthotic patient-care services across the United Kingdom, expanding its distribution area over recent years to include patient-care services throughout the Middle East. “The company has been through quite a transition over the last few years,” says Paul Steeper, chief executive officer of Steeper Group. In the late 1990s the company was sold to a private equity firm, and for more than two decades was in the hands of external owners. The company was transitioning through a further sale process in 2015, but then “the North of England suffered from terrible floods and three of our four manufacturing facilities were seriously flooded,” recalls Steeper. “The sale was subsequently postponed—no one wants a company under five feet of water!”

“Typically, color matching is a challenge and a major factor in patients’ rejection of a prothesis,” explains Steeper. “With this technology, which was initially developed for the cosmetics industry, we can guarantee the color match.” SteeperUSA’s marketing team concentrates on building relationships directly with clinicians and national distribution channels. “We attend all the major O&P shows annually and always enjoy the opportunity to meet with clinicians face to face,” says Steeper. “We also attend all of the major international shows to support our global distributors.” A dedicated SteeperUSA website and social media platforms enable ongoing communications. Among the company’s products is the Select myoelectric hand range, which features nine control modules and a proprietary battery charging system. Steeper notes that the company’s research and development and prosthetics teams have recently been concentrating on developing prosthetic devices to be more accessible, user friendly, and adaptable in design. Paul Steeper has spent his working life at the company, first when it was still in the family business, and then through several private equity owners. “The flood was challenging in the extreme,” he says, “but ultimately provided the opportunity to bring Steeper Group back into family ownership and to create a brand-new facility from which to drive the business forward. Our team did a great job through it all, and we now have a smile on our faces and a strong organization with dedicated employees focused on delivering the highest quality prosthetic and orthotic products and services to a global marketplace.”

Before you renew, get a quick quote at An ENDORSED MEMBER of AOPA

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CO MPLE TE PLA N with our insurance program specifically designed for the orthotics and prosthetics industry. We understand the risks and offer comprehensive protection that allows your business to succeed, whether it’s a patient care facility, central fabrication, manufacturer, or distributor. Practitioners trust us most because we know your business and we know insurance unlike any other program..













Don’t Sleep on the Latest AOPA Member Resource: AOPA Co-OP Are you utilizing your AOPA membership to its fullest? Be sure to visit the AOPA Co-OP at resources/co-op/. A Wikipedia for all things O&P, the Co-OP is a one-stop resource for information about reimbursement, coding, and policy. It is a searchable database that provides up-to-date information on developments in Medicare policy, state-specific legislation, private payor updates, and more. Members can access detailed information on everything from modifiers to product-specific L codes and associated policies. Additionally, members can share information and insights on developments impacting the entire O&P profession.

If you haven't signed up for the Co-OP yet, take part in a free live tutorial on one of the following dates: Friday, October 18 Friday, November 8 Friday, December 6 TUTORIAL


All tutorials take place at noon EST. This is your opportunity to learn about O&P's most comprehensive resource for coding, billing, and reimbursement. Ashlie White, AOPA’s director of strategic initiatives, will demonstrate how to use the Co-OP and answer all of your questions. Contact Betty Leppin,, for details.



Performance Reviews: How Is Your Staff Doing?

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 & Save! Registration Fee

Price Per Seminar

AOPA Members $99.00* Nonmembers $199.00*

* 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. 62


Given the current competitive job market, it’s important to ensure your current employees are fulfilling their responsibilities and that they understand what they need to do to meet their goals. Take part in the October webinar to find out how your performance reviews can facilitate a stronger staffing team. AOPA experts will address the following questions: • How can you identify top players? • What are the best metrics to use in your reviews? • When is the best time to give reviews? • And more.



The Holiday Season—How To Provide Compliant Gifts ’Tis almost the season to be jolly! Learn the right way to demonstrate your appreciation to patients and referral sources while adhering to the guidelines surrounding gift giving. The November 13 webinar will explore the following topics: • When are gifts to referral sources acceptable? • When are gifts to patients acceptable? • What do you need to know about the federal antikickback regulations? • What are some tips for creating a compliant gift-giving policy?




NOV. 3-

2019 AOPA Celebrates Health-Care Compliance & Ethics Week NOVEMBER 3–9, 2019 Make plans to join your AOPA member colleagues in celebrating Health-Care Compliance and Ethics Week (HCEW), November 3-9. In its third year celebrating HCEW, AOPA energized more than 500 members of our community to participate in seminars, educate staff, and share their focus on ethical behavior with their patients and community.


FOLLOW US @AmericanOandP

AOPA is organizing resources, education, prizes, and more to help your organization participate. With a week-long celebration of compliance and ethics, you have a great opportunity to introduce and reinforce your chosen themes. Your plans will rely in part on your organization’s specific needs, but some basic goals may include:

AWARENESS of the Code of Conduct,

relevant laws/regulations, and other reporting methods, the organization’s compliance and ethics staff, etc.

RECOGNITION of training completion, compliance and ethics successes, etc.

REINFORCEMENT of a culture of compliance for which your organization strives. AOPA has developed several free tools and resources to assist you. Visit our dedicated web page for tools, resources and more:


Attend the Las Vegas Coding & Billing Seminar November 4-5 The Mirage 3400 S. Las Vegas Blvd. | Las Vegas, Nevada

AOPA experts provide the most up-to-date information to help O&P practitioners and office billing staff learn how to code complex devices, including repairs and adjustments, through interactive discussions with AOPA experts, colleagues, and more. Meant for both practitioners and office staff, this advanced two-day event will feature breakout sessions for these two groups to ensure concentration on material appropriate to each group. For more information and to register, visit education/coding-billing-seminar/. At this seminar, you will: • Receive up-to-date information on prior authorization and other hot topics. • Ensure your proof of delivery meets Medicare requirements. • Learn how to assess risk areas in your practice. • Learn successful appeal strategies and hints to avoid claim denials. • Practice coding complex devices, including repairs and adjustments. • Attend breakout sessions for practitioners and office staff. • Earn 14 continuing education credits.


The O&P PAC Update provides information on the activities of the O&P PAC, including the names of individuals who have made recent donations to the O&P PAC and the names of candidates the O&P PAC has recently supported. The O&P PAC recently received donations from the following AOPA members*: John Allen, CPO Chris Berdahl, CP Maynard Carkhuff Steve McNamee, CP, BOCO, FAAOP Morris Moncure, BOCP, CPA Ricardo Ramos, CP Eduardo Reyes, CPO



The purpose of the O&P PAC is to advocate for legislative or political interests at the federal level that have an impact on the orthotic and prosthetic community. The O&P PAC achieves this goal by working closely with members of the House and Senate and other officials running for office to educate them about the issues, and help elect those individuals who support the orthotic and prosthetic community. To participate in, support, and receive additional information about the O&P PAC, federal law mandates that eligible individuals must first sign an authorization form, which may be completed online at *This list was created on Aug. 12, 2019, and includes only donations and contributions made or received between May 14, 2019, and Aug. 12, 2019. Any donations or contributions made or received on or after Aug. 12, 2019, will be published in a future issue of O&P Almanac.

Powered Flexion Wrist The Powered Flexion Wrist™ (PFW) combines proportional control and adjustability that allows hands-free targeting of an object. Available now for the MC Hand, ETD, or ETD2. © 2019 Fillauer LLC


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.

Austin Prosthetic Center Inc. 1005 E. Saint Elmo Road, Bldg. 9 Austin, TX 78745 512/937-9310 Member Type: Patient-Care Facility

Southern California Prosthetics Inc. 9272 Jeronimo Road, Ste. 106 Irvine, CA 92618 949/892-5338 Member Type: Patient-Care Facility University of Colorado—Denver 3055 Roslyn Street, Ste. 106 Denver, CO 80238 720/848-3668 Member Type: Patient-Care Facility

Essentia Health-Medical Equipment and Supplies 4418 Haines Road Duluth, MN 55811 218/722-3420 Member Type: Patient-Care Facility


MAY 5–6







KINGSLEY MFG. CO. COSTA MESA, CALIFORNIA, USA 949/645-4401 • 800/854-3479 (CA) 800/824-9704 • (FAX) 949/646-0805 E-MAIL:



Opportunities for O&P Professionals


CO/CPO and/or Technician

Job location key:

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.

- 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 No orders or cancellations are taken by phone. Submit ads by email to 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

Nonmember $678 $830

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

Apply by email to : Mark Goldberg Prosthetic & Orthotic Labs Email:

Inter-Mountain Owner Wanted

Lubbock, Texas INCREDIBLE BUSINESS OPPORTUNITY! National Brace is looking to put a clinician into practice. Please only licensed and highly motivated individuals apply. If you have ever dreamed of owning a practice that is totally affordable with no money down, Medicare, Texas Medicaid, Brightree, vertically integrated purchasing, great lease, and completely turnkey in downtown Lubbock:

National Brace™ Email in confidence to: Email:

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

Member Nonmember $85 $150

For more opportunities, visit:


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



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:

EMPOWERING HUMAN POTENTIAL Their lives are our purpose. Each year we help more than one million people regain their confidence, independence and quality of life. And we’ve been doing it for more than 155 years. All across the country, our team of unsurpassed clinical talent is growing. We’re looking for experienced clinicians who want to make a difference and help lead the future of orthotic and prosthetic care. Experts in our field determined to mentor the next generation of O&P caregivers. Leaders committed to changing lives. Empower your career. Apply today and make a difference.

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.



North Central

North Central


Prosthetic Residency Director

Detroit, Michigan Becker Orthopedic Patient Care is seeking an ABC or BOC credentialed CP/CPO for a full-time position at one of our Metro Detroit offices. Two to three years of experience post certification is desired, but all qualified candidates will be considered. The candidate must possess a strong work ethic, have excellent communication skills, and be comfortable collaborating with other healthcare professionals. Marketing to build referrals will be a significant part of this position. We offer a competitive salary, 401K, and an inclusive benefits package. Send CV with cover letter to: Timothy Piggott 635 Executive Dr. Troy, MI 48083 Email:

St. Louis, Missouri Looking for a CP or CPO who loves to teach others. Must have a minimum of five years of prosthetic experience. This would be an ideal positon for an older practitioner who just wants to teach and not have to worry about meeting sales quotas or the pressure of bringing in new referral sources. We have an extensive existing patient base and the focus would be on teaching new residents. We offer a completive salary and excellent healthcare benefits, including medical, dental, vision, and 401K. If this sounds like it would be right for you, please send your rĂŠsumĂŠ or CV to: Thomas Malone Email:

ORTHOTIST POSITION IN OMAHA, NEBRASKA Nebraska Spine + Pain Center, the most comprehensive spine and pain care practice in the midwest region, has an opening for a Spine Orthotist. REQUIREMENTS:

+ Solid experience in custom fabrication as well as working with off the shelf devices.

+ Fit, test and adjust devices on spine patients. + Excellent communication skills needed to educate and counsel patients and medical team on orthotic plan of care.

+ Minimum of 5 years experience including spine orthotics. For further information, please see our line listing in this publication.

To inquire or apply, please contact Sue Carlson, Director of Clinical Services, at 402-496-5535. Email:



AT Brace Training October 17-18, 2019 Align Technologies, LLC of San Mateo, California is offering Certified Orthotists a limited number of openings for a two-day theoretical and practical training course on the consultation, evaluation, scanning, fitting and follow up of our Align Technologies (AT) scoliosis brace. The AT brace is a semi-asymmetrical scoliosis brace with pressures and expansions built into the positive mold. It is an anterior opening 5/32 finished polypropylene brace with no liner. The AT brace is an upgrade from the standard U.S. manufactured “3-D� scoliosis braces currently on offer. It is a billable TLSO scoliosis brace that provides correction of the Cobb angles while also providing some rotational and sagittal plane correction. This semi-asymmetrical TLSO scoliosis brace provides the highest level of quality and function for the currently available and billable L-codes with the support of experienced team members who are available for the training and guidance of the orthotist. The Certified Orthotists will learn a completely new approach to the treatment of patients with Idiopathic Scoliosis (IS), including the most advanced approaches for the treatment of early onset scoliosis (EOS), Neuromuscular Scoliosis, and Adult scoliosis cases. Upon completion of this intensive and complete semi-asymmetrical TLSO training course, the orthotist will be approved to purchase the AT brace and will have access to the support of our national and international team. Please email Grant Wood at for more details and a course application. Align Technologies Brace Training Course Thursday and Friday, October 17-18, 2019

San Mateo, California | E-mail:


Feature your product or service in Marketplace. Contact Bob Heiman at 856/673-4000 or email Visit for advertising options.

Alps Smart Seal Liner ALPS Flex Sleeve (SFX) has a seamless knitted construction with a 30-degree preflexion which allows for ease of bending and reduces bunching behind the knee. It features our HD Gel, which has a relatively firm nature and provides maximum comfort. Call us or visit www.easyliner. com for more details.


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

Sutti Bounders Store & Return Energy— Mimicking Normal Muscle Function

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.

Airtight Drop-In Lock

New “Sutti Bounders” modular pediatric dynamic elastomers are a patentpending elastomer technology that offer two progressive solutions. Sutti Bounders store and return energy— mimicking normal muscle function to produce both eccentric and concentric contractions and, if needed, a ground reaction 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 bounders or call 800/322-8234

Solvent Replacement Wipes

Coyote’s Drop-In Locks are the first prosthetic locks designed for 3D-printed sockets and traditional drop-in fabrication. Our drop-in locks can create airtight sockets, including dual suspension with a pin. These locks are also water-resistant. For 3D printing, contact Coyote® for your STL and OBJ files. For more information, contact Coyote Prosthetics and Orthotics at 208/429-0026 or visit



+PLUSeries® Solvent Replacement Wipes are specifically designed to replace the use of acetone and other toxic solvents in your work environment, greatly reducing your exposure to harmful toxic chemicals. Learn more at 800/FABTECH or visit

MARKETPLACE Obsidian Running Blades Ready. Set. Go! Get ready for race day with the new Obsidian blade line. The Obsidian Running Blades are available in a posterior mount option for kids and adults. The adult direct mount option offers a pyramid slide for a variety of alignment locations and easy adjustments. The new Obsidian Sprint Blade, intended for elite athletes, provides a curve-hugging split toe along with a snap at toe-off that will push the elite to a new level. Check out for more details.

SOFTIE™ and SOFTIE-TF™ Minimizing the effects of micro tears and/or injury to the incision area at bed rest holds a high priority. FLOTECH® designed the SOFTIE™ and SOFTIE-TF™ to aid easy access for wound care and daily hygiene. We incorporated posterior struts to maximize extension control. Our SOFTIES assist healing and increase the quality of rehabilitation for postsurgical lower-limb amputees. The sockets are soft, nonconstricting, and easy to remove for examinations. Having an inventory of SOFTIE™ and SOFTIE-TF™ sockets allows you to fit most patients at a moment’s notice. They easily fit most sizes, including XL. For more information, visit

LEAP Balance Brace 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

Motion Control’s Next Generation ETD2 A U.S. Department of Defense contract, awarded to Motion Control of Salt Lake City, Utah, partially funded development of a new Electric Terminal Device and wrist system. For many in U.S. military hospitals, the ETD is the first-choice hand replacement for function and versatility. The ETD is the only device that achieves true resistance against water, dirt, dust, and grease. The next generation ETD2 is available now. For more information, contact Motion Control division of Fillauer at 801/326-3434 or visit

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

Arizona AFO’s Moore Balance Brace Check out the latest peer-reviewed, published study substantiating the efficacy of Arizona AFO’s Moore Balance Brace. This randomized controlled trial investigated the long-term impact of a balance ankle-foot orthosis, the Moore Balance Brace, on balance, fear of falling, and physical activity in older adults. Researchers reported not only a decrease in fall risk, but a meaningful reduction in fear of falling, leading to an increase in physical activity. Check out the full study at



MARKETPLACE Proprio Foot® Because the world isn’t flat. 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. See us at AOPA Booth 935 or visit to learn more.

Ottobock’s CCAFO Provides Robust Stability and Support Ottobock’s expertise in custom orthotic fabrication and carbon composites come together to produce an inspiring custom ankle-foot orthosis (AFO). Crafted from carbon prepreg, this lightweight and low-profile AFO provides a solution for individuals with plantarflexion weakness and those needing triplanar support for the foot and ankle. The design stores and returns energy for propulsion while providing function of the soleus muscle and third rocker mechanics (heel-off). This latest addition to the Ottobock line of AFOs is custom-made to match your patient’s specific height, weight, and activity level.

New Skeo Unique Custom Silicone 6Y700 Liner From Ottobock The right solution is Unique. Ottobock’s range of Unique Custom Liners has now been expanded to include the Skeo Unique silicone 6Y700 liner. Plus, we offer the free Custom4U iPad app for easy scanning with a Structure scanner. • Stabilizes residual limbs, even those with significant scarring or soft tissue and unique shapes. • Skin-friendly silicone enables superior connection with the residual limb. • Locking option comes with integrated matrix for minimized pistoning. • Easy handling, easy cleaning. • Suitable for Pin Locking, Valve, Harmony or DVS Vacuum, and KISS suspensions. For more information, call 800-328-4058 or visit

Ottobock Children’s Myoelectric Solutions

For more information, call 800-328-4058 or visit Built for exploration, the Electric Hand 2000 is available in 4 sizes to fit children with upper limb differences as they grow from infancy through adolescence. Paired with the MyolinoWrist 2000, equipped with a ball joint and adjustable friction, children are able to easily position the hand to support a wide range of activities. Visit or speak with your sales representative for more information.







Learn & Earn TOP QUALITY

orthotic, prosthetic and pedorthic education and CE credits from the organization that knows O&P.

It’s as easy as 1-2-3 1. Set up your free personal online account 2. Choose your education and study 3. Take the quiz and print your certificate Membership has its benefits:



Learn more at

Start earning your credits today!



Feature your product or service in Marketplace. Contact Bob Heiman at 856/673-4000 or email Visit for advertising options.

Introducing the Fuzion™ Family of Orthoses Patients experience greater fit, function, and freedom with Orthomerica’s new Fuzion line of custom orthoses. The Fuzion’s design and materials ensure greater patient compliance for a variety of challenging clinical indications. Available for both select adult and pediatric patients. KEY BENEFITS • Proprietary heat-adjustable plastic makes patient management much easier vs. traditional orthoses. • New treatment options for patients historically not candidates for orthotic intervention and management. • Fuzion’s compression design holds the patient in a secure, comfortable position while assisting with spasticity management. • Accommodates volume changes. Call 877/737-8444 or visit


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



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

The Xtern Foot Drop AFO From TurboMed Orthotics This unique AFO was designed for patients suffering from foot drop. It is worn 100 percent outside of the shoe. The Xtern is HCPCS Code L1951 Validated. Turbomed innovative products are now available through distributor partnerships in more than 26 countries. Its unique design and material composition give another meaning to walking and running. There is no limitation with the Xtern for the customers; not even a weight limit! For orthotists and professionals, a trial kit called AT (assessment tool) is available to quickly and easily assess patient compatibility with the Xtern in less than five minutes. Available in USA from Cascade Supply, SPS, Lakes Medical Innovations, Kevin Orthopedic, and Physio Tech. For more information, visit

MARKETPLACE 5280 Drop-In Vacuum Systems Spend more time with your patients. Not chasing vacuum leaks. • 10X more efficient than mechanical pumps • No place for vacuum leaks to occur other than the sealing sleeve • Adjustable vacuum level • Less pump run time with integrated vacuum reservoir • Comfortable soft distal interface • Constant vacuum level provides a consistent socket fit • Apple/Android apps • Smart or on-demand pump styles available. AOPA SPECIAL: ORDER THIS SEPTEMBER AND GET A FREE TOOL SET WHEN YOU ORDER DIRECT For more information, visit or call 720/344-1217.

2019 AOPA Coding Products Get your facility up to speed, fast, on all of the O&P HealthCare Common Procedure Coding System (HCPCS) code changes with an array of 2019 AOPA coding products. Ensure each member of your staff has a 2019 Quick Coder, a durable, easy-to-store desk reference of all of the O&P HCPCS codes and descriptors. • 2019 Coding Suite (includes CodingPro single user, Illustrated Guide, and Quick Coder): $350 AOPA members, $895 nonmembers • 2019 Quick Coders: $30 AOPA members, $80 nonmembers Order at or call AOPA at 571/431-0876.


Advertisers Index Company Align Technologies LLC Alps South LLC Amfit Anatomical Concepts Apis Footwear Company Board of Certification/Accreditation Cailor Fleming Cascade Dafo Inc. College Park Industries ComfortFit Orthotic Labs Inc. Coyote Design ESP LLC Fabtech Systems LLC Fillauer Companies Inc. Flo-Tech O&P Systems Inc. Hanger Hersco Kingsley Motion Control, Division of Fillauer Naked Prosthetics Nebraska Spine + Pain Center OHI Orthomerica Össur Ottobock PROTEOR USA Spinal Technology Inc. Surestep The Bremer Group Company TRS TurboMed Orthotics Uniprox

Page Phone 71 650/375-2231 9 800/574-5426 19 800/356-3668 27 800/837-3888, 330/757-3569 55 888/937-2747 59 877/776-2200 61 800/796-8495 7 800/848-7332 15 800/728-7950 43 888/523-1600 33 800/819-5980 5 888/WEAR-ESP 38-39 800/FABTECH 23 800/251-6398 37 800/356-8324 69 512/777-3814 1 800/301-8275 67 800/854-3749 65 801/326-3434 45 888/977-6693 70 402/496-5535 53 877/780-8382 17 800/446-6770 3 800/233-6263 24-25, C4 800/328-4058 C2 855/450-7300 11 800/253-7868 51 877/462-0711 47 800/428-2304 21 800/279-1865 57 888/778-8726 29




APPLY ANYTIME! BOC Certification. Apply anytime and 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

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 or call 800/848-7332.

October 9

Performance Reviews: How Is Your Staff Doing? Register online at For more information, email Ryan Gleeson at WEBINAR

October 10–12

NC Chapter of the AAOP Scientific Meeting. The Hotel Ballast, Wilmington, NC. For more information, visit or email


October 19

September 11

Veterans Affairs Updates: Contracting, Special Reports, and Other News. Register online at For more information, email Ryan Gleeson at WEBINAR

September 12–14

Midwest Chapter AAOP. Lake Geneva, WI. Visit

September 25–28

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

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, or visit

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


October 7–12

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, or visit


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

November 1

ABC: Application Deadline for Winter CPM Exams. All practitioner candidates have an additional 30 days after the application deadline to complete their residency. Contact 703/836-7114, email, or visit

November 1

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

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

November 4–5

Coding & Billing Seminar. Las Vegas. Book your hotel by October 7 for the $135/night rate. For more information, email Ryan Gleeson at or register online at 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, or

November 13

The Holiday Season—How To Provide Compliant Gifts. Register online at 2019webinars. For more information, email Ryan Gleeson at WEBINAR

December 1

ABC: Application Deadline for February Certification Exams. All practitioner candidates have an additional 30 days after the application deadline to complete their residency. Contact 703/836-7114, email, or visit

December 1

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

December 9–14

2020 January 17–23

US ISPO Pac Rim Meeting. Sheraton Maui Resort & Spa, Lahaina, Maui, HI. Visit

March 19–21

Georgia Society of O&P. Alpharetta, GA. Visit

May 5–6

AOPA Policy Forum. Washington, DC. Visit

May 13–15 NYSAAOP Meeting. Schenectady, NY. Visit September 9–12

AOPA National Assembly. Mandalay Bay, Las Vegas. For general inquiries, contact Ryan Gleeson at 571/431-0836 or, or visit

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

ABC: Written and 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, or visit COMPLETE CONTROL

December 11

New Codes for 2020, Other Updates, and Yearly Roundup. Register online at For more information, email Ryan Gleeson at WEBINAR

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

Let us share your next event! Phone numbers, email addresses, and websites are counted as single words. Refer to 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 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.




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September Solutions Responses to your questions about bid surety bonds, site inspections, out-of-pocket payments, and more


AOPA receives hundreds 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

If I obtained a bid surety bond but was not awarded a contract, will my bond be returned to me?


According to the Competitive Bidding Implementation Contractor, if you obtained a bond and are not offered or awarded a contract, the bond liability will be returned to you within 90 days of the announcement of contract winners. The announcement of contract suppliers is tentatively set for the fall of 2020. In addition, if you are offered a contract and your bid amount for the lead item was above the median composite bid rate, and you elect not to accept the contract, the bid surety bond liability will be returned to you within 90 days of the public announcement of contract suppliers.


For a site inspection by the National Supplier Clearinghouse (NSC), how many times will the inspector stop by or attempt to stop by our facility in order to complete the inspection?




NSC has stated that an inspector will typically make two attempts to gain access to your facility to complete a site inspection. However, there are some caveats for a second attempt to be made. For example, if the inspector comes by and observes clear indications that there is no facility operating at that location, or there are no signs or office hours posted (as required by Supplier Standard 7), it is unlikely the site inspector will make a second attempt to conduct the inspection.



slip that is signed by the patient match the date the patient received the item. However, if you and the patient both enter or provide a date, the date entered by the patient will be considered the delivery date. If a patient wishes to pay out of pocket for a service or item, am I required to have either an initial order or a detailed written order on file?


This question is a little tricky. In short, the answer is no. However, you must take into consideration liability issues and how lack of these items could affect your accreditation standing or local licensure rules. For example, your accrediting body or state licensing board may require you to have prescriptions on file for certain services and items, even if they are cash pay. So, before you provide a service without obtaining a prescription, verify the rules with your accrediting body and state boards.


How much time can I take to respond to an audit request for additional documentation?


On a proof of delivery form, are we able to enter the delivery date, or is the patient required to enter the date he or she received the item when he or she signs the proof of delivery?


Both options would be considered acceptable. The only true requirement, per the Program Integrity Manual, is that the date on the delivery


It depends on the type of audit, but typically you are required to respond to the request within 45 days. This is normally 45 days from the date listed on the request letter and not the date you received the request. In most cases, if you miss the deadline, the claim or claims associated with the additional documentation request will be automatically denied.


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.

Every time it gets better.

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.

Anyone who does billing and coding, even


would benefit from this information.

When asked if they would recommend to others, “I’m

working on the billboard now.”

Want even less risk? Register before October 4 to take advantage of the early bird rate.

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

Register online at

For more information, email Ryan Gleeson at .

8/19 ©2019 Ottobock HealthCare, LP, All rights reserved.

The new C-Brace® Step into the future.™

Meet the world’s first mechatronic stance and swing phase control orthosis system (SSCO®), which controls both the stance and swing phase hydraulically with microprocessor sensor technology. For patients with neurological conditions affecting their legs, C-Brace supports the user during the entire gait cycle and adapts to everyday situations in realtime. It’s time to step into the future.

Request a C-Brace Trial at

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