The American Orthotic & Prosthetic Association
THE MAGAZINE FOR THE ORTHOTICS & PROSTHETICS INDUSTRY
This Jus t In Po
st-Acute Care Bundlin g & Wha t It Mean s to You P age 18
Helping patients find the look that inspires confidence and positive body image
E! QUIZ M Earn
Credits Pages 17 & 34
‘Qualified’ Practitioners: How Many Do We Need? Creating & Maintaining Compliant BAAs
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O&P APRIL 2014, VOLUME 63, No. 4
NEW! This Just In By Adam Stone What is post-acute care bundling and how will it affect your business?
20 Achieving ‘Selfie’ Status
By Christine Umbrell As the nation celebrates Limb Loss Awareness Month, O&P Almanac talks to practitioners and patients about the value of cosmesis, and discusses the evolution in lifelike prostheses.
26 Ensuring Quality During Unprecedented Change
Industry experts Arlene Gillis, LPO, CP, M.Ed., NCOPE president, and Brian Gustin, CP, founder and CEO of Forensic Prosthetic and Orthotic Consulting, share their views on how we define a qualified O&P practitioner and what the demand for their services will be in the coming years.
Reimbursement Page Interest, recoupment, and overpayments during appeals
32 Compliance 00 Corner
E! QUIZ M Earn
AOPA Contact Page How to reach staff
At a Glance Statistics and O&P data
Pages 17 & 34 Re-evaluating Business Associate Agreements
Facility Spotlight New England Orthotic and Prosthetic Systems
President’s Corner Insights from AOPA President Anita LibermanLampear, MA
42 AOPA Membership 00 Applications 43 Marketplace
Products and services for O&P
Opportunities for O&P professionals
In the News Research, updates, and company announcements
AOPA Headlines News about AOPA initiatives, meetings, member benefits, and more
AOPA Answers Expert answers to your FAQs
Upcoming meetings and events
O&P Almanac (ISSN: 1061-4621) is published monthly by the American Orthotic & Prosthetic Association, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314; 571/431-0876; fax 571/4310899; email: almanac@AOPAnet.org. Yearly subscription rates: $59 domestic; $99 foreign. All foreign subscriptions must be prepaid in U.S. currency, and payment should come from a U.S. affiliate bank. A $35 processing fee must be added for non-affiliate bank checks. O&P Almanac does not issue refunds. Periodical postage paid at Alexandria, VA, and additional mailing offices. Postmaster: Send address changes to: O&P Almanac, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314. For advertising information, contact Bob Heiman at 856/673-4000 or email email@example.com.
APRIL 2014 O&P Almanac
President’s IN THE NEWS corner
Enhancing the O&P Almanac Experience
ost of us have the wonderful reward of being involved in some way with the outcomes patients enjoy as a result of timely O&P treatment. Individuals with deformities or musculoskeletal weaknesses can be supported and, in many cases, see improvements that result in better activities of daily living, reduced pain, and even permanent skeletal changes because of O&P professionals like you. Many people have learned to walk again after limb loss thanks to targeted O&P solutions. In short, making things better is an everyday part of our professional experience. In the spirit of improvement: I need your help in making the O&P Almanac even better for you. Further enhancing the O&P Almanac has become one of my personal crusades this year because, long before joining the AOPA Board, this magazine was—and continues to be—a must-read for me. The breadth and the depth of editorial coverage always bring me a piece of new clinical or business management information that I can put to use. Each month, it delivers something that makes things better for me, my colleagues, and our patients. One of my favorites is the Facility Spotlight series that shines a light on a specific O&P practice or supplier member by sharing the unique story of how the business began and how it continues to operate in today’s challenging marketplace. My other favorite is the new quarterly Compliance Corner—appearing on page 32—that helps keep me up to date on the issues that directly affect the revenues (and costs) of our businesses. What’s your favorite part of the O&P Almanac? What other topics would you like to see covered? How can we enhance the look and feel of the book? In my quest for making things better and, in this case, making the magazine better for you, the answers to these questions are essential. Tell me what you think would make the O&P Almanac an even better professional magazine by sending me an email at info@AOPAnet.org. And be sure to respond to the research feedback study currently in the field, located at http://bit.ly/1gOOd16. Most importantly, tell your suppliers that when they advertise in the O&P Almanac, they help create the financial wherewithal to support AOPA’s advocacy mission that is designed to help everyone in the O&P field—not only to make them better, but to make sure they are here to celebrate the AOPA centennial in 2017 and beyond. That’s what makes the O&P Almanac different! Thank you for taking a few minutes of your busy day to read this column. Sincerely,
Anita Liberman-Lampear, MA President, AOPA
PS: Our AOPA Political Action Committee (PAC) has served us well. Legislators supported by our PAC have been responsible for good things, such as the $10 million in Department of Defense research funding. Please support the annual Wine Auction AOPA PAC Fundraiser by attending (sign up when you register for the September Assembly); donating a favorite wine, jewelry item, or even a trip (for details, email Devon Bernard at firstname.lastname@example.org); asking for a donation form (also available on AOPA’s website); and, of course, bidding high. Mark your calendars and please join me for this special event, Friday, Sept. 5, 2014 at 6:30 p.m., at the Mandalay Bay Resort and Casino in Las Vegas. It will be the best hour you spend raising money for a worthy cause.
O&P Almanac APRIL 2014
AOPA IN THE Contact NEWS INFORMATION AMERICAN ORTHOTIC & PROSTHETIC ASSOCIATION (AOPA) 330 John Carlyle St., Ste. 200, Alexandria, VA 22314 AOPA Main Number: 571/431-0876 AOPA Fax: 571/431-0899 www.AOPAnet.org EXECUTIVE OFFICES
MEMBERSHIP & Meetings
BOARD of DIRECTORS
Thomas F. Fise, JD, executive director, 571/431-0802, tfise@AOPAnet.org
Tina Moran, CMP, senior director of membership operations and meetings, 571/431-0808, tmoran@AOPAnet.org
Don DeBolt, chief operating officer, 571/431-0814, ddebolt@AOPAnet.org
Maynard Carkhuff Freedom Innovations, LLC, Irvine, CA
Kelly Oâ€™Neill, CEM, manager of membership and meetings, 571/431-0852, koneill@AOPAnet.org
President Anita Liberman-Lampear, MA University of Michigan Orthotics and Prosthetics Center, Ann Arbor, MI
O&p Almanac Thomas F. Fise, JD, publisher, 571/431-0802, tfise@AOPAnet.org Josephine Rossi, editor, 703/914-9200 x26, email@example.com Catherine Marinoff, art director, 786/293-1577, firstname.lastname@example.org Bob Heiman, director of sales, 856/673-4000 email@example.com Lia K. Dangelico, managing editor and contributing writer, 703/914-9200 x24, firstname.lastname@example.org Stephen Custer, production manager, 571/431-0810, scuster@AOPAnet.org Christine Umbrell, editorial/production associate and contributing writer, 703/914-9200 x33, email@example.com
Stephen Custer, communications manager, 571/431-0810, scuster@AOPAnet.org Lauren Anderson, manager of membership services, 571/431-0843, landerson@AOPAnet.org Betty Leppin, project manager, 571/431-0876, bleppin@AOPAnet.org AOPA Bookstore: 571/431-0865 Government affairs Joe McTernan, director of coding and reimbursement services, education and programming, 571/431-0811, jmcternan@AOPAnet.org
President-Elect Charles H. Dankmeyer Jr., CPO Dankmeyer Inc., Linthicum Heights, MD Vice President James Campbell, PhD, CO Becker Orthopedic Appliance Co., Troy, MI Immediate Past President Tom Kirk, PhD Member of Hanger Inc. Board, Austin, TX Treasurer James Weber, MBA Prosthetic & Orthotic Care Inc., St. Louis, MO Executive Director/Secretary Thomas F. Fise, JD AOPA, Alexandria, VA
Devon Bernard, assistant director of coding reimbursement, programming and education, 571/431-0854, dbernard@AOPAnet.org Reimbursement/Coding: 571/431-0833, www.LCodeSearch.com
Jeff Collins, CPA Cascade Orthopedic Supply Inc., Chico, CA Alfred E. Kritter Jr., CPO FAAOP, Hanger, Inc., Savannah, GA Eileen Levis Orthologix LLC, Trevose, PA Ronald Manganiello New England Orthotics & Prosthetics Systems LLC, Branford, CT Dave McGill Ă–ssur Americas, Foothill Ranch, CA Michael Oros, CPO Scheck and Siress O&P Inc., Oakbrook Terrace, IL Scott Schneider Ottobock, Minneapolis, MN Don Shurr, CPO, PT American Prosthetics & Orthotics Inc., Iowa City, IA
O&P Almanac Publisher Thomas F. Fise, JD Editorial Management Stratton Publishing & Marketing Inc. Advertising Sales RH Media LLC Design & Production Marinoff Design LLC Printing Dartmouth Printing Company
Copyright 2014 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 Almanac. The Almanac is not responsible for returning any unsolicited materials. All letters, press releases, announcements, and articles submitted to the 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.
O&P Almanac APRIL 2014
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AT IN THE A GLANCE NEWS
Highlights of the Sochi Paralympics The 2014 Winter Paralympic Games has drawn to a close but there is still much to celebrate, including the many medals and milestones earned by Team USA and athletes from across the globe. U.S. athletes took home 18 medals during the 2014 Paralympic Games in March:
“What an honor it is to make history not only for the first-ever Paralympic snowboarding event, but also for the first-ever USA men’s sweep for the Paralympics.” —Keith Gabel, Bronze Medal Winner, Para Snowboard Cross
1 5 8 14
0 2 1 3
Ice Sledge Hockey
1 0 0 1
U.S. men swept the inaugural para-snowboarding cross event:
• • •
Evan Strong, U.S.
Michael Shea, U.S.
Keith Gabel, U.S.
U.S. snowboarder Amy Purdy’s time in the para-snowboarding cross event, which earned her a Bronze medal.
Number of volunteers at the Games.
Number of Bronze medals won by U.S. skier Stephanie Jallen in women’s super combined—standing and women’s super G—standing.
O&P Almanac APRIL 2014
Score of the final ice sledge hockey tournament, in which Team USA defeated Russia to win Gold.
12 km and 5 km
Distances U.S. cross-country sit skier Oksana Masters traveled to earn Silver (12 km) and Bronze (5 km) medals.
Sources: www.sochi2014.com/en/paralympic; www.teamusa.org/US-Paralympics. 8
Photo: Joe Kusumoto Photography
Total number of Paralympic athletes who competed in the 2014 Winter Games.
I chose ABC for my facility accreditation because I want— my patients to get the best care possible u
the best reputation in my community u
my practice to be a success. u
IN THE NEWS
AOPA Responds to DME MACs’ Guidance for Split Code Orthoses With the release of the 2014 Healthcare Common Procedure Coding System codes, CMS has created a new subset of 55 prefabricated codes, which it deems to be off-the-shelf (OTS) orthoses. It also created a series of 23 “split codes,” or orthoses that can be provided either OTS or customized to fit a specific patient by an individual with expertise. The creation of the split codes and the OTS codes has raised many questions, including who will make the decision whether an orthosis requires proper fitting by a trained individual or can be delivered as an OTS item without additional fitting and training. Also in question is documentation needed to support claims for services that require proper fitting by a qualified individual. On Feb. 28, 2014, the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) released a joint policy bulletin entitled, “Correct Coding—Definitions Used for Off-the-Shelf, Custom Fitted
and Custom Fabricated Orthotics (Braces).” This policy bulletin was subsequently retracted on March 7, 2014 without explanation as to the reason for the retraction. On March 27, 2014, the DME MACs released a revised version of the policy bulletin entitled, “Correct Coding—Definitions Used for Off-the-Shelf, Custom Fitted Prefabricated Orthotics (Braces)-Revised.” In addition to the publication of the revised policy bulletin on the proper coding of OTS versus custom-fitted orthoses, the DME MACs simultaneously published revisions to the Local Coverage Determinations and policy articles for ankle-foot orthoses, knee-ankle-foot orthoses, knee orthoses, and spinal orthoses that incorporated the provisions of the policy bulletin into the actual medical policies. The policy bulletin contains definitions of both OTS and customfitted orthoses, along with guidelines regarding when a product should be billed using an OTS code and
AOPA continues to seek regulatory refinements to ensure that the term “off-the-shelf orthosis” is appropriately defined and that only those items that meet the statutory definition of OTS are considered eligible to be included in future rounds of the competitive bidding program.
when it should be billed using a custom fitted code. AOPA has several concerns regarding statements made in the policy bulletin, including the introduction of the term “substantial modification” when describing custom fitted item; statements regarding the use of CAD/CAM technology and its effect on both OTS and custom-fitted codes; and the failure of the DME MACs to recognize certified orthotic fitters as qualified providers of custom-fitted orthoses. The complete policy bulletin can be found at www. medicarenhic.com/viewdoc.aspx?id=2645. AOPA has prepared comments in response to the DME MACs’ definitions, particularly their definition of “off the shelf” and their explanations of the devices that are required to be custom-fit. AOPA continues to seek regulatory refinements to ensure that the term “off-the-shelf orthosis” is appropriately defined and that only those items that meet the statutory definition of OTS are considered eligible to be included in future rounds of the competitivebidding program. AOPA also encourages its members to submit independent comments as well. Questions regarding the DME MAC Correct Coding announcement may be directed to Joe McTernan at firstname.lastname@example.org or Devon Bernard at email@example.com.
DME MAC Reports High Error Rate in Spinal Orthoses Claims National Government Services, which operates the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC), has reported the results of a widespread prepayment probe review of lumbosacral orthoses and thoracolumbosacral orthoses. Of the 100 claims selected for review, 83 were denied—including 19 claims that were denied due to a lack of provider response. This resulted in an overall error rate of 83 percent.
O&P Almanac APRIL 2014
This finding is an important reminder to O&P facilities to respond to all requests for documentation, as failure to respond will result in an automatic denial of the claim and will contribute to higher error rates. The full report can be found on the National Government Services website, www.ngsmedicare.com. Questions regarding this issue may be directed to Joe McTernan at jmcternan@ aopanet.org or Devon Bernard at firstname.lastname@example.org.
IN THE NEWS
Winners of free registrations to the 2014 AOPA National Assembly:
AOPA Makes a Big Showing at AAOP Meeting The American Academy of Orthotists and Prosthetists celebrated its 40-year anniversary in Chicago during its Annual Meeting & Symposium in February, and AOPA representatives were on hand to join in the events. Practitioners from across the country met to engage in educational sessions and networking, hear lectures, and see presentations of free papers and poster presentations. It may have been cold outside, but things heated up quickly as the AOPA booth in the Exhibit Hall was a hotbed of prizes and giveaways. Meeting attendees who stopped by the AOPA booth had a chance to spin the AOPA Wheel of Prizes with a chance to win gift cards, AOPA product discounts, and prizes provided by Mandalay Bay Las Vegas, the host of the 2014 AOPA National Assembly. One lucky winner each day won a free registration for the 2014 AOPA National Assembly, which will be held in Las Vegas, Sept. 4-7, 2014. AOPA was represented at the conference by Anita Liberman-Lampear, MA, AOPA president; Tom Fise, JD, executive director; Kelly O’Neill, manager of membership and meetings; and Joe McTernan, director of coding and reimbursement services.
Sy Rosen, CO, LO
Steve Corlew, CO
Joe Hofmeister has been named chief executive officer of Tamarack Habilitation Technologies Inc. Joe Hofmeister
Amy PalmieroWinters, an amputee endurance runner and program director at A Step Ahead Prosthetics & Orthotics, finished the Ultraman Florida race to become the first athlete with a prosthesis to complete one of these Amy PalmieroWinters extreme triathlons.
Rachel Sidle, CPO, LPO
Kelly O’Neill, AOPA’s manager of membership and meetings, and Joe McTernan, director of coding and reimbursement services, staff AOPA’s booth.
people in the news
Steve Corlew, CO, has joined the Petoskey, Michigan, office of Active Limb and Brace as O&P clinic manager.
Amy Purdy, a doubleamputee U.S. Paralympic snowboarder profiled in the February 2014 issue of the O&P Almanac, is a contestant on ABC’s 2014 Amy Purdy season of “Dancing With the Stars,” which debuted in March. Steve Sherman has joined Ability Dynamics as vice president of sales. He will lead national sales efforts in expanding sales in North America and the Steve Sherman company’s expansion into worldwide markets.
Left to right: AOPA President Anita Liberman-Lampear, MA; NCOPE Chair Arlene Gillis, M.Ed., CP, LPO, FAAOP; and AAOP President Michelle J. Hall, CPO, FAAOP, at the Academy Meeting.
In MEMORIAM Edward John Roman Edward John Roman, CP, LO, passed away on February 27 at the age of 65. Roman worked at Diamond Fab in Milwaukee. He also was a founding member of allied health education programs that assisted with implementing the Orthotics, Prosthetics, and Pedorthics Practice Act in the State of Illinois.
APRIL 2014 O&P Almanac
IN THE NEWS
Update on O&P Alliance Challenge to PODs The questionable self-referral practices of physicianowned distributorships (PODs)—physicians who own distribution facilities for O&P devices—and the potential conflicts of interest has been a long-running issue for the O&P industry. In a May 23, 2013, letter to Daniel Levinson, inspector general of Health and Human Services (HHS), the O&P Alliance wrote, “With the exception of certain prefabricated off-the-shelf orthoses or supply items, allowing the provision of other types of O&P care by referring physicians opens the door to overutilization, potentially suspect medical judgment, unfair competition and increased costs to the Medicare program and its beneficiaries.” The letter also called attention to an alert published March 26, 2013, by the Office of the Inspector General (OIG) on potential fraud on self-referred implantable medical devices. The Alliance letter noted that the “same principles would apply when evaluating arrangements involving other types of physician-owned entities.” The HHS OIG responded to the Alliance in a letter dated Sept.10, 2013, indicating that recommendations the Alliance made for solving the problem “do not fall within the jurisdiction of the OIG and are more appropriately directed to CMS.” In response to the Alliance suggestion “that OIG increase its enforcement activities with respect to physician ownership of O&P laboratories and include the analysis and observation of physician-owned O&P laboratories in its
The Amputee Coalition, in conjunction with members of its Scientific and Medical Advisory Committee, has created a body mass index (BMI) calculator to help individuals with limb loss assess their weight status by calculating their BMI. Visit the Limb Loss Resource Center page on the Amputee Coalition’s website, www.amputeecoalition.org.
O&P Almanac APRIL 2014
fiscal year 2014 work plan,” the letter said, “We will consider your observations and recommendations as we plan future activities. In addition, we welcome any specific information that you can provide regarding abuse practice.” The O&P Alliance followed up with a Nov. 18, 2013, letter to CMS Administrator Marilyn Tavenner indicating the OIG recommended that the Alliance bring the profession’s areas of concerns to the attention of the administrator. The Alliance letter referenced the In-Office Ancillary Services Exception (IOAS), which allows certain tests and other services described as Designated Health Services to accommodate certain “legitimate physician business arrangements.” The Alliance pointed out “that the IOAS exception and other loopholes in Medicare regulations related to O&P services are being exploited and do not conform to the IOAS original exception’s intent.” The letter went on to recommend that these loopholes should be eliminated. The response to the Alliance letter from CMS of Jan. 8, 2014, was helpful to the extent that it acknowledged the potential for a problem and allowed, “The information you have provided is helpful as we continue consider physician self-referral policy options.” This statement is an indication that the O&P Alliance’s persistence on this issue may bear fruit at some point. The full text of the letters and documentation can be viewed at www.aopanet.org/op-alliance-updates/.
BUSINESSES in the news
Ability Prosthetics and Orthotics has unveiled a new anniversary logo for its 10th anniversary.
The Board of Certification/ www.bocusa.org Accreditation (BOC) has been honored with a Stevie Award for Sales & Customer Service in the “Best Use of Technology in Customer Service” category. BOC was recognized for its exceptional integration of technology and customer service. BOC also has announced it is a 2014 Silver Level Sponsor of OPAF, the Orthotic & Prosthetic Activities Foundation. LIMBS International has announced it will be sending 150 legs to a partner clinic, The Center for Disability in Development, in Bangladesh.
New England Orthotic & Prosthetic Systems has opened a new patient-care center in Poughkeepsie, New York. The facility will be staffed by Kimberly Hertz, BOCO, cFOM, CMF, COA, and David Zwissler, BOCO, BOCP. Rx Textiles Inc. and SPT Technology Inc. have announced a new company name: Paceline Inc. Rx Textiles acquired SPT Technology three years ago, and the new name is a reflection of the unified company.
IN THE NEWS
Ottobock Pays Tribute to Inventor Richard Glabiszewski As first reported in the February issue of O&P Almanac, Richard Glabiszewski, a well-known inventor and designer who left a profound legacy on modern prosthetic design, passed away in early 2014. Recently, Ottobock President and CEO of U.S. Healthcare Brad Ruhl contacted O&P Almanac to share his unique perspective in the following tribute to Glabiszewski’s legacy:
Together with Ottobock then-owner Dr. Max Näder and the research and development team of the 1960s, Richard Glabiszewski designed and patented the first “pyramid” system in 1969, which is found in virtually every modern modular lower-limb prosthetic system in use today. Glabiszewski’s invention so fundamentally changed the world of prosthetics as it was known then that we would be remiss if we didn’t acknowledge just how disruptive this technology was at
Left to right: Dr. G.G. Kuhn, Richard Glabiszewski, Dr. Max Näder.
the time. Prior to this invention, the world of lower-limb prosthetics was still dominated by the use of wooden knee-shin components together with wooden foot-ankle components. Imagine what the life of the prosthetist and the lives of their patients would be like today without this fundamental platform technology. But Richard, Dr. Näder, and their team were far from finished with their developments. They went on to design the very first “modular” stance control knee (3R15/3R49) that will forever be identified as the modern version of the old wooden “safety knee.” I doubt very much that there’s a prosthetist alive today anywhere in the world that hasn’t either used or at the very least become intimately familiar with this knee. It has become the most widely
The first “pyramid” system.
used knee in the history of prosthetics and remains the worldwide standard today. Between these two relatively simple yet tremendously impactful inventions, Richard and his team of designers forever changed the face of prosthetics and he will be sadly missed by those who knew him and by those who knew of him. As one of the latter, and of course as one who knows how important these inventions were to our company, I felt it was important to share this information about the loss of a true and great pioneer in our industry. In the words of current Ottobock CEO Professor Hans Georg Näder, “Richard Photos and illustration: Ottobock
was a gifted engineer and designer and he fully understood how to implement his ideas in the workshop. With his departure we have lost a great craftsman, but we will keep Glabi’s humor with us always. Ottobock owes him great thanks.” The first “modular” stance control knee (3R15/3R49).
APRIL 2014 O&P Almanac
Reimbursement Page By Devon Bernard, AOPA government affairs department
Maintaining Cash Flow During Appeals Everything you need to know about interest, recoupments, and overpayments to manage your finances
Editor’s Note: Readers of Reimbursement Earn 2 Page are now eligible Business CE Credits to earn two CE credits. SEE PAGE 17 After reading this column, simply scan the QR code or use the link on page 17 to take the Reimbursement Page quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.
E! QUIZ M
O&P Almanac APRIL 2014
s part of the Medicare, Medicaid, and Supplemental Children Health Insurance Plan Benefits Improvement and Protection Act, and the Medicare Modernization Act of 2003 (MMA), Medicare laid down the final pieces of the Medicare appeals process, including the current five levels, the timeframes for filing appeals, and when/how Medicare may recoup money as part of the appeals process. For a quick review, here are the five levels: 1. Redetermination. After you receive a determination on a claim, you have 120 days from receipt of the claim determination to file an appeal. Once the request for redetermination is submitted, it will be reviewed by someone other than the person who made the initial determination, and it will be reviewed by the Durable Medical Equipment Medicare Administrative Contractor that processed the initial claim. 2. Reconsideration. The second level of appeal is handled by a Qualified Independent Contractor (QIC); the current QIC is C2C Solutions Inc. All reconsideration requests must be made in writing and within 180 days of receipt of the redetermination decision. 3. Administrative Law Judge (ALJ) Hearing. The ALJs will perform an independent review of the claim based only upon the information
that has been submitted during prior levels of appeal. An ALJ hearing must be made in writing and within 60 days of the receipt of the reconsideration decision, and you must meet a minimum amount in controversy (AIC) of $140.
Once you receive the demand letter, Medicare will begin to apply interest on the amount you owe—the principle—and this interest will be assessed for each 30-day period until the debt (the principle plus any interest) is paid in full. 4. Review by the Departmental Appeals Board (DAB), also known as a Medicare Appeals Council. A request for a DAB review must be made within 60 days of receipt of the ALJ decision. The DAB will review only the information that is on file, and will only review the decision of the ALJ with which you disagree.
5. Judicial Review. This level of appeal involves you filing a civil lawsuit against the Medicare program in federal court within 60 days of receiving the DAB’s decision. An AIC of $1,430 must be met. In previous Reimbursement Page columns, we have reviewed in detail the Medicare appeals process outlined above, including tips on how to navigate the process effectively and successfully. But what we have not covered in detail is the monetary side: interest rates, interest payments, recoupments, and overpayments.
Recoupment Time and Interest After an audit (whether it is a Recovery Audit Contractor, Comprehensive Error Rate Testing, or any other postpayment audit), Medicare will issue a demand letter notifying you of a payment denial and the overpayment amount—the amount you now owe Medicare. The date you receive the demand letter starts the appeals time clock. As indicated above, you have 120 days to file your first level of appeal, but it also serves as the starting point for the recoupment timeframe, or the repaying of a Medicare debt through reduction of present/future claims or by other means. Once you receive the demand letter, Medicare will begin to apply interest on the amount you owe—the principle—and this interest will be assessed for each 30-day period until the debt (the principle plus any interest) is paid in full. It is important to note that the interest is not a compounded interest, but rather a simple interest, and it is only applied to the amount of the original principle that remains unpaid. This interest rate is not static, but is adjusted each quarter by the Secretary of the Treasury. For example, the previous interest rate, which was in effect from Oct. 18, 2013, to Jan. 20, 2014, was 10.125 percent,
The limitation on recoupment only stops the recoupment process; it does not stop the accrual of interest. This means that interest is still accruing on your principle amount, and since you are not paying down the principle during the appeals process the amount owed will increase each 30-day period. and the current rate is 10.25 percent. With the receipt of the demand letter, you also must decide how you wish to handle the overpayment request. Here are the most common options: • You can voluntarily pay back the overpayment up front and all at once, and you will not be subject to paying any interest on the overpayment amount as long as the payment is made within 30 days of receiving the demand letter. • You can voluntarily request that your claims be offset. • You can do nothing, and by the 41st day after receiving the demand letter Medicare will automatically, involuntarily, begin to offset your claims. If you have your claims offset, either voluntarily or involuntarily (starting on the 41st day after receiving the demand letter), Medicare will immediately begin to withhold payments from your future claims until the overpayment amount has been paid back in full, plus any interest that may accrue. Here is an example of how interest is applied to debt when you choose to have your claims offset. If you owed $1,000 and it was 60 days until you received your next Medicare payment, and it was for $800, you would now owe $1,017, using the current annual interest rate of 10.25 percent. As stated above, the interest is simple interest and is applied to the principle amount
owed every 30 days, so the interest of .08452 (10.25 divided by 12 for your 30-day rate) of $1,000 is $8.50 x 2 for 60 days. The $800 Medicare payment is applied to the interest first ($17) then to principle amount (the original $1,000 you owed), and your new principle and amount owed is now $217. After the next 30-day cycle, you will owe $235.34, the sum of 10.25 percent annual interest applied to the new principle ($217) and the new principle. This cycle would continue until the debt is paid in full. It is important to note that if Medicare collects any interest from you, it must repay that amount back to you if you are successful during the appeals process.
Recoupment Protections If you choose to have your claims offset you do have some protections provided to you by the MMA. Mainly, you may have the recoupment/ offset process halted as you appeal the overpayment request found in the initial demand letter. The MMA prohibits Medicare or its contractors from recouping any overpayments during the first two levels (redetermination and reconsideration). To delay any recoupments from starting, you must file your redetermination request within 30 days of receiving the demand letter, rather than the traditional 120-day timeframe you have to file a redetermination. If the request for a redetermination is filed
APRIL 2014 O&P Almanac
It is important to note that if Medicare collects any interest from you, it must repay that amount back to you if you are successful during the appeals process.
after 30 days, the recoupment process will begin on the 41st day but will be halted once the request for appeal has been received. As you proceed to the reconsideration level of appeal you may continue to have the recoupment process postponed, as long as you file the reconsideration request within 60 days of receiving the redetermination decision letter, rather than the normal 180 days. If you file your reconsideration request past the 60-day window, the recoupment process will begin, but as soon as you file your request it will cease. There are two key items to be aware of about the limitation on recoupment protections provided to you by the MMA. First, the limitation on recoupment only stops the recoupment process; it does not stop the accrual of interest. This means that interest is still accruing on your principle amount, and since you are not paying down the principle during the appeals process the amount
O&P Almanac APRIL 2014
owed will increase each 30-day period. Second, the ability to stop the recoupment process ends 30 days after your receive the reconsideration decision letter. This means that 30 days after the second level of appeals has concluded, Medicare will continue with the recoupment process until the original debt and any subsequent interest has been paid in full, even if you continue to proceed through the appeals process. On the flipside, if a claim denial/ overpayment request is overturned in your favor during one of the first two levels of appeal you have the ability to collect interest on the initial claim amount or the principle amount. The interest, which will be simple interest, can only be collected and will only be paid if the overturned amount is not repaid within 30 days of the final determination. So, if you donâ€™t receive your money within 30 days of a successful redetermination or reconsideration request, you are due interest.
But what about appeals at the ALJ level or higher? As stated above, the recoupment process will resume 30 days after the reconsideration level of appeal concludes. This means that Medicare will automatically begin to recoup/offset your claims until the original debt and any interest is paid off in full, or until you are successful in your appeal, whichever comes first. For claims involving recoupments at this point and beyond, Medicare may pay interest on monies recouped during the time that a claim is awaiting a final decision at the ALJ level or higher and any other monies recouped during the earlier levels of appeals. The interest that may be paid is only payable on the principle amount recouped, meaning Medicare will only pay you interest on the money recouped to satisfy the original debt, and it will not pay interest on the interest it recouped. But if Medicare collects any interest from you, it must repay that amount back to you if you are successful during any level of the appeals process. The interest you may collect is referred to as 935 interest, according to the MMA. There is a major caveat associated with collecting 935 interest payments from Medicare. The interest can only be assessed and collected on money that was recouped via â€œinvoluntary payments.â€? So, if you paid back the money in one lump sum when you received the initial demand letter, or you requested that Medicare offset your future payments, you are not eligible to collect 935 interest. If money was recouped from you involuntarily, your must determine how much 935 interest is owed to you by Medicare. There are three factors involved when calculating 935 interest: time, rate, and amount. 1. Time is the total number of days from the recoupment date to the date you receive a final decision divided by 30, because the interest is assessed/accrued on 30-day periods. 2. Rate is the annual rate of interest that is in effect at the time the final
Rate of Interest at Time of Final Decision (Rate)*
Recoupment Amount (Amount)
Length of Time Money Was Held (Time)**
Amount of 935 Interest Owed
March 17, 2013
May 5, 2013
June 16, 2013
*The rate becomes .008542 (10.25 percent divided by 12). ** The time must be in multiples of 30-day periods.
decision is made. If a decision was made today, the interest rate would be 10.25 percent, and to convert that to a monthly rate you have to divide it by 12. 3. Amount is the money that has been involuntarily recouped and applied to the principle amount of the debt, and doesn’t include any money that was recouped and applied to interest owed. If you multiply these factors (time X rate X amount), you will have calculated the amount of 935 interest owed to you on each recoupment action. Keep in mind that a single claim/ overpayment may have multiple recoupment actions before it is paid in full. So, when calculating the total amount of 935 interest owed to you, you may have to do multiple calculations and add the totals together. For example, the chart above details a claim worth $10,000 that involves three separate recoupment actions to pay off the debt, reflects the current interest rate of 10.25 percent, and has a final ALJ decision date of Jan. 21, 2014. After you have calculated the 935 interest owed to you, you have to determine how much of it will be paid to you. If you have any other outstanding overpayments, Medicare will apply the amount collected by the 935 interest first to those overpayments and any excess monies will then be refunded back to you. If you have other questions about the appeals process, the limitation on recoupment provisions, or 935 interest, please contact AOPA or visit the Medicare website and the Medicare
manuals, primarily Chapter 3 of the Medicare Financial Management Manual, which can be located at www.cms.gov/Regulations-and-Guidance/ Guidance/Manuals/Internet-OnlyManuals-IOMs.html. a
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Devon Bernard is assistant director of coding reimbursement, programming, and education for AOPA. Reach him at dbernard@ aopanet.org.
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www.oandpstudyguide.com APRIL 2014 O&P Almanac
By Adam Stone
This Just In
Crash Course: Post-Acute Care Bundling What is it, and why does it matter to you?
magine if every amputee, every spinal surgery patient, every stroke patient in your local hospital or rehab facility was discharged essentially carrying a 90-day warranty. Suppose the hospital was obliged to cover every service that patient needed, including his or her initial O&P care, for the next 90 days. Now imagine that in order to support the patient’s warranty, the hospital had established a bidding process for one party to provide all the therapy visits, all the wheelchairs, and, yes, all of the O&P services for that patient. Suppose all care for those patients went to that low bidder?
O&P Almanac APRIL 2014
That is post-acute care (PAC) bundling. Now think about how it would impact your practice. It’s potentially catastrophic. Earlier this year, Congress was considering PAC bundling language and indicated to AOPA representatives that O&P would be included in the legislation. On behalf of its members, AOPA acted quickly to ensure that O&P was excluded from the first iteration of the federal plan. Considering the potential impact on your business, all O&P practitioners need a crash course on PAC bundling and this near-miss situation.
Losing Choice PAC bundling is not, in theory, a terrible idea. It’s just a terrible idea for O&P. “Where bundled payments have arguably worked reasonably well has been when you have an acute condition with clearly defined treatment protocols of relatively short duration,” says David McGill, AOPA board member and vice president of reimbursement and compliance at Ossur. “But when you look at O&P you don’t have those things. You are looking at a very different world, a world that is inherently more complex.” The problem lies with the “warranty,” wherein the federal government (or private payer) makes one payment to one provider for all the things the patient needs for those first 90 post-hospital days. In this way, your local hospital might in theory drive down total costs to the minimal per-patient level. But there’s a big price to pay for such “savings,” especially in O&P. Consider the consequences if a major national hospital chain and similar facilities—Tenet, Hospital Corporation of America, Health South—received such contracts from the fed, and each selected one low-bidding O&P provider for all the facilities in its seven-state region. For practitioners, the warranty formula would almost certainly leave them in dire financial straits. Suppose,
for example, bundling were to become standard practice, with the medical “quarterback” charged with portioning out a lump sum among all players. Who gets how much? How will funds get portioned out? O&P will most likely come up short. To determine their percentage of the total payment, all of the practitioners would have to have a detailed understanding of the treatment each would deliver beforehand. But there’s no formula on the table for making that calculation. PAC bundling also isn’t good for patients. The feds will say they are focused strictly on measuring quality, but at what cost to the patient? Bundling would inherently interfere not just with the fabrication of braces and artificial limbs, but with the fundamental relationship between patient and provider. Medicare beneficiaries would find themselves limited in their choices as they seek out a health-care provider with whom they will be engaged in what is usually a lifelong relationship. Post-acute O&P care does not last for 90 days. It goes on for weeks, months, even a lifetime. So there is an inherent divergence from the outset between the structure of the bundle and the practice of O&P. Again, there are circumstances in which this practice might work. Hip or knee replacements are likely examples. There’s a clearly defined procedure, well-established follow-up and clear, commonly accepted protocols supported by a huge body of research. In many aspects of O&P the appropriate treatments are more fluid, at once more idiosyncratic and less well-defined. “I don’t think anyone in the O&P industry will tell you that there has been enough research and that we have clearly proven all the benefits that out treatments provide, in a data-driven way,” says McGill. O&P practitioners know what works, and they are skilled in its delivery. The problem arises, in part, in the need to put a price tag on procedures that will naturally vary from patient to patient. PAC bundling would set that
price regardless of the circumstances, declaring payments at whatever levels the lowest bidder will offer. The timeliness of treatment also would likely be at risk as practitioners attempt to deliver care while simultaneously containing costs according to a preset formula. Past experience has shown that providers have responded to bundling by delaying and denying O&P patient care until the patient was discharged, when it was clear that Medicare Part B assumed the cost of O&P treatment. Patient quality of care declined with these inappropriate delays in access to O&P care, often irreversibly compromising independent living and relegating the patient to nursing home care.
Bundling would inherently interfere not just with the fabrication of braces and artificial limbs, but with the fundamental relationship between patient and provider. Saving the Docs? Experts say the real impetus for PAC bundling is to prevent further cuts to physician fees. A noble enterprise, perhaps, but one fraught with possible unexpected consequences. PAC bundling has been discussed for the past 10 years, as part of the larger conversation among those seeking some check to the astronomic growth rate of health care. Just recently, Congress considered a permanent “doc fix,” a way to eliminate the so-called SGR or sustainable growth rate formula. This formula triggers significant legally mandated reductions in the Medicare physician fee schedule.
To permanently fix the physician fee schedule would cost nearly $140 billion. Lawmakers looked at PAC bundling as the major “pay-for” to offset those costs. CMS has already initiated some demonstration projects on PAC bundling, and congressional staff believe this strategy alone can generate $100 billion of the needed savings. In late March, President Obama’s budget indicated the intent to save $100 billion by implementing PAC bundling. In the last week of March, congressional committees floated a draft for the IMPACT bill. Instead, Congress stepped in March 31 and passed another band-aid, one-year “doc fix,” and kicked the can down the road again. So, don’t even begin to think this could never happen. Back in mid-February, AOPA heard that congressional staff was considering PAC bundling language, and went in to visit key staff. AOPA was told O&P is in the bundle. AOPA argued that this would interfere with the right of the Medicare beneficiaries/ patients to choose the health professional with whom they would work in partnership over a lifetime to maintain their mobility, and thereby their independence. Congressional staff requested AOPA’s suggestions for actions to protect those patients. AOPA sent a specific proposal that was endorsed by the O&P Alliance on February 26. On March 3, AOPA received word from congressional staff that at least for the initial draft of the bill, they agreed with AOPA that all O&P services should be shifted to be excluded from the PAC bundling bill. O&P professionals dodged a bullet for now, thanks to AOPA’s quickfooted and effective response. But stay tuned. This one will almost certainly keep coming back around to threaten O&P again. a
Adam Stone is a contributing writer to O&P Almanac. Reach him at adam. email@example.com.
APRIL 2014 O&P Almanac
’ e fi l e ‘S
Practitioners should work to educate patients so they understand that a socket must fit properly before a prosthesis can look good.
As with all patients, determine what their goals are for their devices at the onset, then collaborate to achieve the right function and appearance.
It’s important to be forthcoming about costs, including what will be covered by an insurance company or Medicare, and to advocate for patients’ needs.
O&P Almanac APRIL 2014
COVER STORY By CHRISTINE UMBRELL
In the spirit of Limb Loss Awareness Month, are you advocating for your patients’ body image needs?
oday’s patients are educated consumers who arrive at O&P facilities knowing what they want— often requesting a specific “look” for their O&P componentry. Whether they’re seeking a prosthesis that is so lifelike that it looks real, or a high-tech device with no coverings for optimal speed and athleticism, many patients expect practitioners to deliver an artificial limb with a predetermined appearance. “Patients come in more educated. Everyone surfs on their phones, and they come in with lots of questions, asking about all of the devices they’ve seen online,” says Erik Schaffer, CP, owner of A Step Ahead Prosthetics & Orthotics in Hicksville, New York. Though patients who have done their research generally “make for a better consult,” according to Schaffer, it can be challenging to deliver a device that meets patients’ cosmetic criteria while performing at top function. “The most cutting-edge component is of little use if you cannot wear the prosthesis comfortably.” “Most practitioners will say, ‘Let’s get the function right first,’” says Leslie Pitt Schneider, JD, RN, who is both an O&P consumer and an industry veteran. A member of the Executive Committee of the Amputee Coalition and Ottobock’s clinical and regulatory affairs manager, Schneider has been an above-knee amputee since the
age of 6. In years past, says Schneider, practitioners often would ask patients to compromise on the cosmesis of their prostheses in order to get the function right. But these days, more options are available to achieve balance in both areas. “We have more freedom in [developing] a system that is tough and beautiful,” says Schaffer.
Form and Function With a wider range of products on the market, ensuring the right device and proper fit for each patient remains paramount. “Once you get people functional and comfortable, then they want to go to the next level to look good,” says Schaffer. He starts with technologically advanced systems and then builds “great coverings over them.” Skin systems are getting stronger, lighter, more realistic, and easier to put over the mechanical parts of technologically advanced prostheses, says Schaffer. Many patients prefer a lifelike appearance for their prosthetic coverings, for a variety of reasons. For new amputees, wearing a prosthesis that looks similar to the missing limb can play an important role in the all-important rehabilitation process: If the prosthesis helps the patient return to looking more like his or her pre-amputation self, he or she may want to wear the new device and participate in the necessary rehab.
APRIL 2014 O&P Almanac
Photo: Touch Bionics
yet functional prostheses crafted from high-definition silicone and hand-painted to match skin tone and appearance. They are designed with functional capabilities that can assist in activities of daily living such as pushing, pulling, light grasping, and typing. They also can be personalized with hair, freckles, moles, scarring, or tattoos. Additionally, Ottobock and several other O&P companies offer custom silicone prosthetics that can be individualized to the patient.
Many patients seek artificial limbs that look “real” so their limb loss is not noticeable. Schneider offers the example of a woman who loses a breast and gets a breast implant—that woman wants the new breast to look as normal as possible, to match the shape and size of the existing breast. “A leg isn’t exactly the same as a breast, but for some patients, restoring the leg to as close to its previous look is just as important,” she says.
In today’s consumerdriven patient environment, O&P professionals need to be aware of all of the cosmetic offerings and be prepared to work with patients to give them the look they want.
proud of her gait and the fact that most people can’t tell she is an amputee. “It’s very important to me how the cover looks.” Schneider says a lifelike prosthesis is favored by many adults with professional-type careers, who want the focus during their business day to be more about their work and less about their appearance. “For those of us who prefer lifelike prostheses, it boosts our confidence because the device is so realistic,” says Schneider. She prefers not to be labeled as “disabled” or have others take note of her physical difference. “For a lot of women who wear cosmetic legs who work in professional settings and wear suits or skirts, body image matters,” she says. Creating realistic-looking limbs also can be important for the youngest patients, whose parents may seek lifelike devices: “I can line up 1,000 pediatric patients’ parents; they all want their child’s feet back. Being able to do that can have a psychological impact on patients and parents,” says Schaffer.
More Choices Schneider describes herself as “old school” in her devotion to her lifelike prosthesis. “I’ve gone through a lot to get to the ‘pretty leg,’” she says. She is
O&P Almanac APRIL 2014
Today’s manufacturers offer a variety of choices in terms of skin tone and realistic appearance. For example, Touch Bionics offers livingskin products, a line of passive
Photo: Erik Schaffer
A patient holds up her sound hand next to a Touch Bionics livingskin passive functional device.
Schaffer designed A Step Ahead so he can complete all aspects of O&P care within his own facility; his office space features a 6,000-square-foot silicone division, where coverings are designed using the company’s own Skin Tones System. For each patient, the process involves a life casting (taking a mold of the patient’s sound limb, if possible), fabricating the shin and foot sections, color matching the patient’s skin tones, and installing the finished system over the prosthesis. Schaffer’s facility attracts an international clientele with a variety of needs and wants. One recent patient requested a lifelike prosthesis that would be compatible with wearing 4-inch stiletto heels. “We spent more
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Amputees Take Pride in Body Image During Limb Loss Awareness Month April is Limb Loss Awareness Month, and the Amputee Coalition is encouraging individuals with limb loss to be proud of their bodies and their achievements.
O&P Almanac APRIL 2014
Leslie Pitt Schneider, JD, RN
Photo: AOPA/Marinoff Design LLC
“Taking time during Limb Loss Awareness Month to recognize our individually unique physicalities as contributing factors to making us individually and uniquely strong, is what we can do as individuals, and as a community,” says Leslie Pitt Schneider, JD, RN, a member of the organization’s Executive Committee, and author of the limb-loss lifestyle blog www.onelifeonelimb.com. “It shows others about acceptance, about empowerment, and about empathy. In doing so, it shows others that lives are for living and if living life with limb loss is what makes us unique, then it also makes us strong.” The Amputee Coalition is sending a message this month that “regardless of when your amputation happens, there are no limitations as to what your life can be,” says Schneider. To that end, the Amputee Coalition is challenging support groups across the country to help raise limb loss awareness by planning and holding walk/run/roll events in their communities to benefit the Coalition and its mission to empower people affected by limb loss to achieve their full potential. Half of the proceeds raised by each participating support group will go directly toward a fund at the Amputee Coalition to cover the registration fee(s) of sending one or more members from that
Photos from the Limb Loss Education Day (LLED) held during the 2013 AOPA World Congress in Orlando.
support group to the Coalition’s 2015 National Conference, held in Tucson, Arizona, July 23-25, 2015. Any amount not used by support groups to cover registration fees in 2015 will go toward the Kathy Spozio Bridge to Ability Scholarship program to help send new amputees to the conference.
May, June, and the Rest of the Year Though Limb Loss Awareness Month will shine a light on O&P on the national level, the Amputee Coalition will continue to increase awareness through communitylevel educational events. Called Limb Loss Education Days (LLEDs), these events are designed to bring high-quality patient education and recreation to the local level, where amputees live, work, and play. “Our regional LLEDs have been hugely successful because they make our programs accessible, from both a cost and a travel perspective, to
amputees and their families,” says Susan Stout, interim president and chief executive officer of the Amputee Coalition. Each day-long LLED features educational presentations as well as adaptive recreation activities. Practitioners are asked to spread the word about these events and encourage patients to participate in an upcoming LLED at one of the following locations: May 3
New York City
Raleigh/Durham, North Carolina
Fort Yates, North Dakota
September 13 Philadelphia October 11
November 22 Palm Desert, California
For more information, visit www.amputee-coalition.org/eventsprograms/limb-loss-education-day/.
Photo: Erik Schaffer
Erik Schaffer, CP, owner of A Step Ahead Prosthetics, in his workspace.
‘Showing the Bones’
Though lifelike appearance is important to many demographics, practitioners should recognize that some patients may choose to “show the bones,” says Schaffer—go without coverings and let the devices speak for themselves. This can be true both for financial reasons—because some insurance companies limit what they will cover, and it can be economical to leave off the covering—and for the “cool” factor. Among the younger male demographic in particular, Schneider says many are embracing more technical, and more high-functioning, devices, such as the ones worn by wounded warriors. “Many amputees are saying, ‘I own it,’ in wearing high-tech prostheses; they are becoming more acceptable” and more favored by some over lifelike designs, Schneider notes. “The really active people don’t care as much about cosmesis,” notes Schaffer. If a covering might weigh too much or slow them down, athletes often choose to forgo coverings. Schaffer also has found that “kids love to ‘show the bones,’ too.” But Schaffer believes 90 percent of the population remains “aesthetically
concerned.” And even the most ardent athletes often have several devices, including both high-tech sports devices and more cosmetically appealing everyday components. Some high-profile amputees take advantage of coverings to “make a statement” instead of adopting a lifelike appearance. David Rotter, CPO, LPO, C.Ped, clinical director of prosthetics for Scheck and Siress in Chicago, began responding to this demand seven years ago by creating custom-laminated C-leg covers. Rotter offers patients the opportunity to individualize their covers.
“A prosthesis is not only a functional device,” says Rotter. “We want the final look to be an expression of their personality, saying something about who they are.” He has designed a variety of patriotic and militaryinspired covers—such as the ones he created for Rep. Tammy Duckworth (D-Illinois) and Paralympic swimmer Melissa Stockwell, CP. “I want the prosthesis to be representative of the patient.”
A Patient/Practitioner Team Approach
than eight hours sculpting and forming a covering for the below-knee prosthesis, and working to get the skin tones exactly right.”
Paralympian Melissa Stockwell, CP, wears her patriotic prosthetic covering.
In today’s consumer-driven patient environment, O&P professionals need to be aware of all of the cosmetic offerings and be prepared to work with patients to give them the look they want, given reimbursement considerations. “Practitioners shouldn’t be surprised to have patients coming to them with new device ideas,” Schneider explains. And practitioners should be ready to listen to those ideas and work collaboratively with patients. “Most prosthetists already have a high level of empathy and respect for their patients,” says Schneider. “Going forward, they’ll need to continue to listen to and advocate for what’s in the best interest of their patients.” a Christine Umbrell is a contributing writer to O&P Almanac. Reach her at firstname.lastname@example.org.
APRIL 2014 O&P Almanac
Ensuring Quality During Unprecedented Change Experts discuss education, workforce demand, and the survival of the profession
recently announced a four-year
project to secure federal funding to expand existing O&P education programs at NCOPE-accredited teaching institutions or to create new master’s level programs—a move that drew terse commentary from the industry. Some challenged the need for a master’s level qualification for certification and additional practitioners in the field; others defended those claims. Inspired by these comments,the O&P Almanac enlisted two O&P experts to engage in a discussion of the merits and share their viewpoints on these critical topics. NCOPE President Arlene Gillis, LPO, CP, M.Ed., is one of the most respected educators in the O&P field and currently heads up the St. Petersburg College of Orthotics and Prosthetics program. Former AOPA president and board member Brian Gustin, CP, took over his father’s O&P practice in the 1980s and expanded it before selling it in 2006. Today, he is founder and CEO of Forensic Prosthetic and Orthotic Consulting.
O&P Almanac APRIL 2014
O&P Almanac: How does the profession progress with the existing reality that O&P has a master’s level education requirement? Arlene Gillis: The master’s requirement will contribute greatly to not only our profession’s continued progress, but to its survival in the changing world of health care. O&P professionals with a master’s level education will have the skills to streamline processes, quantifiably measure our quality of care, utilize and expand evolving technologies, and justify orthotic and prosthetic care to pay sources. O&P is not the first field to debate this change. Take physical therapy, for example, which has extended its education requirements to a doctoral degree in response to the changing health-care environment. Public views of health, legislation, and public funding for health services have changed over the past several years. The advances in technology and services have expanded the breadth of health care in all fields. Technology has certainly broadened O&P’s reach and responsibilities with myoelectrics, microprocessors, CAD/CAM, FES, etc. Academic standards must evolve concurrently with this expanding scope of practice. Advanced degrees reflect all of the progress we in the O&P industry have worked so hard to achieve and the increased level of care we are providing for our patients. For those individuals who may be unfamiliar with O&P, such as other health-care professionals, legislators, new patients, and insurance representatives, a master’s degree
translates into greater respect. New practitioners have advanced skillsets, and this new degree “title” will hopefully open the doors for them to be involved in conversations with physicians and other health-care professionals and increase O&P professionals’ role in the medical decision-making process for more patient-centered care. From this requirement, the O&P field also can expect increased research activity and more evidenced-based practice, which will support and defend our treatment methods. Master’s level professionals are leading the way in not just interpreting and performing evidence-based research, but in utilizing, communicating, and spreading that information to other health-care professionals. We are learning from each other and propelling advances in our field at an exemplary rate now. These may be challenging times, but if we adapt to them, they can be very exciting times, too.
Brian Gustin: The master’s degree requirement is self-imposed with no assurance this level of education will benefit the patient or the industry as a whole. Having graduate-level degrees in any profession is a good thing, however, the requirement to make it the barrier to entry for O&P seems to be born out of an image concern rather than a need. Indicating a master’s degree as the minimum entry level to
provide care suggests anything less will result in poor, or at least inadequate, care and diminished credibility. Of course this is not the case, given how care is currently provided. O&P seems to struggle with its image as a “vendor/ supplier” in the health-care system and is seeking status as a “provider.” The requirement of a master’s degree will do little to change this image as long as the focus of the education is on the device, rather than the patient. Today, much of what goes into a device is pre-manufactured and simply assembled. The differentiation factor for practitioners is no longer how they manually “craft” the device; it is their ability to articulate why a specific device is medically necessary for the patient’s systemic condition(s). Whereas, in the past, the primary role of the practitioner was to make a device, the primary role of the practitioner of tomorrow will be to effectively communicate why his or her proposal is medical necessary. To accomplish this, O&P needs to focus more attention to critical thinking and effective writing skills. Requiring a master’s degree does not necessarily guarantee one possesses these skills. Critical thinking and writing skills have to be effectively taught, and they have to be recognized as the foundation for being able to justify and provide good care. O&P should have master’s and even doctorate level degrees. These higher levels of education are needed in the field of comparative effectiveness research, which has been a topic of concern for decades. All one has to do is read payer policies for the rationale used to make coverage decisions and it is clear the results of the current body of knowledge focuses on the functional aspect of the device, not the functional aspect of the patient. Reduced metabolics or improved biomechanics are meaningless to payers; payers want to know how X improves independence and/or reduces overall cost for a specific patient population. Practitioners with higher levels of education are necessary for this type of research, but this level of education is not necessary to provide good care to patients.
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O&P Almanac: How does the profession assure the patient community that there is a steady flow of qualified O&P professionals to address the clinical needs over the next 20 years?
Gillis: Looking at the statistics we have from the U.S. Department of Labor, the orthotic and prosthetic field is growing faster than other workforces, faster even than other health-care fields. O&P is reported to have a growth rate of 36 percent. There were an estimated 8,500 O&P professionals as of 2012, and the Department of Labor estimates that number will rise to 11,500 by the year 2020. This is an increase of 300 new O&P professionals each year. Given the current number of annual O&P graduates, the industry will not meet this requirement. As a result, some patient populations may be underserved. This number also does not reflect the growing median age of current clinicians nearing retirement, which will increase the need even more. Some regions estimate they will lose 15 to 20 percent of their workforce to retirement in the next five years. The master’s requirement coupled with NCOPEaccredited residencies ensures a quality professional; however, awareness, outreach, and geography tend to be our downfall. Some areas generally saturate quickly, but how many of us have heard stories from patients about having to travel far distances to find an orthotist or prosthetist? Or even patients—and health-care professionals, for that matter—who were
O&P Almanac APRIL 2014
completely unaware of our services? This reflects lack of public awareness and education of our field. We owe it to the patient community to focus on promotion of the field and orthotic and prosthetic awareness so that we can recruit committed individuals, educate and train them, and make sure that underserved areas and patient populations are being adequately served.
Gustin: The question becomes: What is a qualified professional, and how many do we need? As we have seen increasing technology on the device side, so have we seen increasing technology on the process side of providing O&P services. What was in the past both technologically and economically impossible and quite possibly unacceptable will become possible and acceptable. Yet O&P has chosen to cling to its past, making the mastery of manual skills and an increased education level the definition of “qualified.” Should not the definition of qualified be the appropriate application of care for a given condition, irrespective of how one arrives at the outcome? Indeed even CMS has
recognized this in the fee schedule through the “productivity adjustment,” which decreases the fee schedule by a percentage due to increased technological advancements, eliminating compensation for many manual tasks of the past. Dentistry is an example of an industry that has embraced this technological advancement. The tasks dentists perform today are nothing like what they did 30 years ago. Dentistry has changed the role of its dentists while improving patient care. O&P is allowing the doctrines of its past to become dogma, preventing change from occurring. Patients, payers, referral sources, and traditional O&P will suffer because of this rigidity. O&P has tried to quantify the “quality” factor through state licensure efforts. However, to get any of these bills passed, proponents have had to exempt many other care providers, or face stiff opposition, effectively killing these bills. In reality, these bills have handcuffed O&P practice owners to their past, preventing them from adapting their business models to the changing economics of health care. Providers who have been exempted are free to do whatever is necessary, from a business perspective, to provide O&P services. And despite these licensure bills, the percentage of active Durable Medical Equipment, Prosthetics, Orthotics, and Supplies provider numbers assigned to O&P decreased 8 percent between 2006 and 2010, while the percentage assigned to physicians increased by the same 8 percent, according to the National Supplier Clearinghouse.
We also need to discuss how many qualified practitioners are needed in the field. Looking at Medicare charge data from 1992-2010, we see an evident trend—decreasing utilization of most O&P services, but primarily on the prosthetic side. Keep in mind, the total patient population can be predicted from the Medicare sample population, assuming Medicare represents approximately 30 percent of the payer mix. Additionally, correlating a national amputation rate with preparatory codes (the vast majority of these will be used on new amputees), one can estimate the percentage of new amputees who actually receive a prosthesis. This acquisition rate has declined as well. The total number of amputations is remaining flat due to the combination of an increasing demographic population with improved limb-salvage intervention. One conclusion for the declining acquisition rate could be patients’ medical conditions are so advanced by the time an amputation is necessary, they are no longer candidates for prostheses. Considering only the number of ABC-certified prosthetic practitioners, the workforce could be reduced by 50 percent, and the total number of billable events for new and existing prosthetic patients would equal two per week per practitioner. Similar results are seen on the orthotic side as well, according to the aforementioned Medicare charge data. The interesting fact here is the inverse relationship between lowerlimb custom and non-custom orthotic devices and who is providing each. The utilization rates on lower-limb custom codes are declining rapidly year-over-year; however, it is primarily a certified orthotist providing the care. Conversely, non-custom codes are increasing rapidly; however, the provider is generally someone other than a certified orthotist. It would seem licensure efforts are protecting a diminishing return.
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O&P Almanac: How can we accomplish this—and perhaps how will the mix of professional skills need to be tweaked—in an unprecedented environment of dramatic cost-cutting, upheaval, and consolidation that characterize today’s health system?
Gillis: Health-care changes and cost-cutting measures will continue to be big battles for our profession. O&P practitioners have traditionally worn many hats and handled most aspects of patient care, from assessment and fabrication to documentation and practice management. The demand on O&P professionals’ time is increasing now with the surge in documentation and evidence required from pay sources. In order to provide patientcentered and quality care, we will need to streamline processes and bridge the gap in services. Additional support personnel will be needed to continue to serve the same numbers of patients we have in the past. By utilizing qualified individuals such as technicians, fitters, pedorthists, and O&P assistants, everyone, including the O&P practitioners, can concentrate their time on the aspects of patient care in which they are most proficient. With the clinician coordinating, these extenders of care put the patient at the center and allow the practitioner time to complete the appropriate evaluations and documentation, and more opportunities to utilize tools and avenues available, such
business management and outcome measurement software and apps to better combat things like Recovery Audit Contractor audits. This does not just increase efficiency, it increases the level of care each patient receives. In a world where orthotic and prosthetic clinicians must prove efficacy of their treatment plans or face nonpayment, the responsibilities of exceptional patient-centered care must be dispersed amongst the entire O&P team. The multidisciplinary team approach to health care has proven to increase patients’ quality of care; this is just an example of that on a smaller scale. When discussing these challenges, my team at St. Petersburg College of Orthotics and Prosthetics gathered a lot of input from the O&P workforce and our advisory board members over the years. We recently interviewed an O&P regional director on the topic and were told that, with the increased diabetic dysvascular patient population coupled with the therapeutic foot-care program, practices were using high-level certified prosthetists and orthotists to fit the vast majority of these patients.
The negative effect was the inability to service hospitals and nursing homes in a timely and efficient manner. With increases in the soft goods business, these practices were challenged with lower revenues and higher patient volume. Additionally, residents were receiving marginal residency training because in some areas there was no choice but to use them to see this large patient population. Although the residents need to learn these modalities, it was obvious with the changes to the educational programs (master’s level) that we needed to start to cultivate our extenders in the form of certified pedorthists, orthotic fitters, and fitter assistants, as well as certified O&P assistants. By utilizing these groups and providing the necessary training we can create a business model that can fully service all of our current and future needs. Of course, that is with the understanding that all practitioners must always use good judgment and maintain compliance.
Gustin: We know the effectiveness of our devices and services is being scrutinized: The changing code descriptors and coverage language, and the variety of audits with resulting reimbursement claw-backs are proof. Right now, the majority of those who are appealing through to the Administrative Law Judge level are successful, primarily because of technicalities and/or ambiguities in the policy. In the near future, these arguments will have to be more clinically based. We will need to understand how to think about and write effective medical briefs (for example, Letters of Medical Necessity) advocating for our patients’ medical needs based on sound comparative effectiveness research, which is relevant to the payers. We will need to recognize that patients suffer when their care is denied or delayed due to poor writing and thinking skills by their practitioners. Too often, O&P practitioners blame the payer, who denies the claim or prior authorization request. In reality, O&P practitioners
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have failed to understand the needs of their customer (defined by who pays for service), and the result is their client (defined by who receives service) is not treated. This is poor care. The clinic structure also will need to change. We need to design operational systems, with definable and repeatable processes that are coordinated across the administrative, clinical, and technical aspects of care. Once this is done, we can create measurable standards of care, so we can learn what works and what doesn‘t and refine our processes and standards for continuous improvement. This will create a patientcentric culture within an organization. We can then enter the medical and payer community with realistic results as to the value of the services we provide to improve patients’ lives in a cost-effective manner. If we want to be thought of as medical providers/professionals, it is not enough to simply add educational credentials. We must do what is expected of all medical providers. a
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Enables a complete disconnect immediately below the socket in seconds without the removal of garments. Can be used where only the upper (above the Coupler) or lower (below the Coupler) portion of limb needs to be changed. Also allows for temporary limb replacement. All aluminum couplers are hard coated for enhanced durability. All models are interchangeable.
The A5 Standard Coupler is for use in all lower limb prostheses. The male and female portions of the coupler bolt to any standard 4-bolt pattern component.
The F5 Coupler with female pyramid receiver is for use in all lower limb prostheses. Male portion of the coupler features a built-in female pyramid receiver. Female portion bolts to any standard 4-bolt pattern component. The Ferrier Coupler with an inverted pyramid built in. The male portion of the pyramid is built into the male portion of the coupler. Female portion bolts to any 4-bolt pattern component.
NEW! The FA5 coupler with 4-bolt and female pyramid is for use in all lower limb prostheses. Male portion of coupler is standard 4-bolt pattern. Female portion of coupler accepts a pyramid.
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NEW! The FP5 Coupler is for use in all lower limb prostheses. Male portion of coupler has a pyramid. The Female portion of coupler accepts a pyramid.
The Trowbridge Terra-Round foot mounts directly inside a standard 30mm pylon. The center stem exes in any direction allowing the unit to conform to uneven terrain. It is also useful in the lab when tting the prototype limb. The unit is waterproof and has a traction base pad.
APRIL 2014 O&P Almanac
Compliance Corner By Devon Bernard, AOPA government affairs department
The New Rules for BAAs Ensure your agreements comply with updated requirements; here’s how
Editor’s Note: Readers of Compliance Corner Business CE are now eligible to Credits earn two CE credits. SEE PAGE 34 After reading this column, simply scan the QR code or use the link on page 34 to take the Compliance Corner quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.
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If a business associate agreement has expired then a new one is required, and if it has not expired you will want to begin negotiations with the business associate and establish a timeframe to modify the agreement before the Sept. 23, 2014, deadline.
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Featured in the January 2014 issue of the O&P Almanac, the inaugural installment of the Compliance Corner focused on your O&P facility’s breach policies and notice of privacy practices. This installment will review your business associate agreements (BAAs), and determine if, as a result of the Jan. 25, 2013, Omnibus Rule, they are still compliant or if they need to be amended and to what extent they need to be amended. There is still time to become compliant.
he Omnibus Rule allows for a grandfathering period for amending or updating any current BAAs. If a BAA was in effect prior to the release of the Omnibus Rule, you have until Sept. 23, 2014, or the date that your current agreement expires, to make any required revisions—whichever comes first. However, any BAA created on or after Jan. 25, 2013, must already be compliant with the new Omnibus Rule.
First Steps Based on these compliance dates, the first thing you should do is to verify when your current BAAs expire. If a BAA has expired then a new one is required, and if it has not expired you will want to begin negotiations with the business associate (BA) and establish a timeframe to modify the agreement before the Sept. 23, 2014, deadline. As you know, a BA is a person or entity that provides services on behalf of or to covered entities (you as an O&P provider), and requires the use and disclosure of protected health information (PHI)—the data created by a health-care provider that is used to
identify an individual for the purpose of treatment and billing. The role of the BA has not changed, but the definition has changed. Now, a BA is any entity that creates, receives, maintains, or transmits PHI on behalf of a covered entity, and includes any subcontractors that a BA may enlist to carry out its duties. This change means that some of your prior informal arrangements with certain entities may now require a formal BAA because the entities may be considered BAs. Some examples of BAs include but are not limited to third-party billers, clearinghouses, or accrediting/credentialing organizations. Some examples of companies/entities/individuals that are not considered BAs include but are not limited to hospitals, your referring physicians, your Internet provider, or your mailman. The second thing you will want to do is examine your dealings with outside entities/individuals to determine if they meet the new definition of a BA and see if a BAA may be required. You can find out if an entity/individual is a BA by asking the following questions:
If you answered “yes” to any of these questions, then a BAA would be required. If you answered “no,” then a BAA may not be required. If you are still unsure whether or not an individual/entity is acting as a BA, consult with your attorneys or consider having the individual/entity sign a BAA. However, given the new rules, an individual/entity may be less inclined to sign a BAA if they are not required to do so.
• Is the PHI being disclosed to someone in the capacity of his or her job as a member of your workforce? • Is the PHI being disclosed to a health-care provider (for example, physicians, hospitals, and others) for treatment purposes? • Is the PHI being disclosed to a health plan/insurer for payment purposes? • Is the PHI being disclosed to another covered entity? If you answered “yes” to any of the above questions, then a BAA would not be required. If you answered “no” then a BAA may be required. And BAA status can be drilled down even more by considering the following questions: • Does the entity/company create, receive, maintain, or transmit PHI for the purpose of any of the following activities: claims processing, administration, data analysis, utilization review, quality assurance, patient safety activities, billing, benefits
management, practice management, or similar activities? • Does the entity/individual provide you with any of the following services that require the disclosure of PHI: legal, accounting, consulting, data aggregation, management, administrative, accreditation, or financial? • Will the entity/individual be able to access PHI on a regular basis, and/ or is there a possibility that the PHI in its control could be compromised?
Creating, Amending BAAs Once you have determined who is a BA and when a BAA is required, the next step is to write the new BAA or amend your current one. To help with this endeavor, let’s quickly review what exactly the BAA is and what its purpose is. The BAA is a contract between a covered entity and a BA that provides assurances to the covered entity that the BA is properly handling and safeguarding all PHI.
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APRIL 2014 O&P Almanac
The BAA also defines what type of services the BA will perform for the covered entity and the amount of PHI the BA will need to carry out these activities. The Omnibus Rule also made some changes in how a BA is to interact with a covered entity, and the obligations of a BA under a BAA with a covered entity. These changes are prompting the creation of a new or amending of an old BAA. For example, a BA is now required to ensure proper accounting of all disclosures of PHI that have been made, and to notify you of any breach of PHI. Also, BAs are now required to directly comply with the Health Insurance Portability and Accountability Act (HIPAA) standards and rules just as providers are—instead of being able to choose whether or not to follow the rules as they could in the past. This direct liability and compliance to HIPAA now must be included in your BAAs, and these provisions also apply to any subcontractor or agents your BA may employ or use on your behalf. Given these changes, if you don’t have agreements with your current BAs, or you need to create BAAs, keep in mind that the document should contain the following 10 elements or criteria: 1. Establish what uses and disclosures are permitted by the BA. 2. Establish that no other uses or disclosures of PHI are allowed unless granted by the BAA or as required by law. 3. Require that the BA implement safeguards to prevent unauthorized use or disclosure of PHI. (This should include implementing requirements of the HIPAA Security Rule with regard to electronic PHI.) 4. Require the BA to report to any uses or disclosures of PHI not provided for by its contract, including the reporting of breaches of unsecured PHI. 5. Require the BA to assist you with granting individuals access to their PHI, amending their PHI, and/or accounting of disclosures of their PHI.
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Business associates are now required to directly comply with the Health Insurance Portability and Accountability Act standards and rules just as providers are—instead of being able to choose whether or not to follow the rules as they could in the past.
6. To the extent the BA is to carry out a covered entity’s obligation under the Privacy Rule, make sure the BA complies with the requirements of the Privacy Rule. 7. Require the BA to make its records/ policies relating to the use and disclosure of PHI available to you and to Medicare. 8. Require that, at the termination of the BAA, the BA return or destroy all PHI. 9. Require the BA to ensure that any subcontractors it works with agree to the same restrictions and conditions that apply to the BA with respect to PHI. 10. Ensure you have the authority to terminate the BAA if the BA violates a material term of the BAA. If your current BAA covers most of the above criteria, you may choose to amend your current BAA to remain compliant. Below are some key items to include in your amended agreements, but make sure the amended BAA is specific to your needs and the BA’s needs. • Include a section that allows you to verify that the BA is in compliance with the HIPAA security and privacy regulations.
• Ensure that the BA will report all breaches to you in a timely manner, and that these notifications are done in a standard format. • If a BA uses any subcontractors, ensure that the subcontractor(s) agrees to the same restrictions and conditions you apply to the BA. • Make sure the BA complies, where appropriate, with the Security Rule with regard to electronic PHI. • To the extent the BA is to carry out the covered entity’s obligation under the Privacy Rule, the BA must comply with the same requirements of the Privacy Rule that apply to the covered entity in the performance of said obligations. For guidance purposes, the Office of Civil Rights has created a template you may use when creating/reviewing your current BAA. Access its website at www. hhs.gov/ocr. Lastly, it is important to note that you could be held accountable for the actions of your BA or its subcontractors. It will all depend on how much authority is granted to you and/or the BA under the agreement. So, be sure to review your BAAs carefully and be sure it doesn’t impose any unnecessary burdens or liabilities to you or the BA. a Devon Bernard is assistant director of coding reimbursement, programming, and education for AOPA. Reach him at dbernard@ AOPAnet.org.
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Facility Spotlight By Deborah Conn
Shared Success NEOPS offers practice managers part ownership, resulting in motivated and innovative staff
Facility: New England Orthotic & Prosthetic Systems Location: Connecticut, New York, Massachusetts, Rhode Island, and Vermont Gordon Childs, CPO, OTR, of the Middlebury office, helps a patient with her leg brace.
Owner: Ronald J. Manganiello History: 16 years in business
hen Ron Manganiello started New England Orthotic & Prosthetic Systems (NEOPS) in 1998, he was following a successful career at Hanger Orthopedic, a company he purchased in 1985. Along with partner Ivan Sabel, Manganiello had taken Hanger from annual sales of $7 million to a public company with $400 million in annual sales in 11 years’ time. But Hanger was headquartered in Bethesda, Maryland, and Manganiello grew weary of commuting from his home in New Canaan, Connecticut, where he lived with his wife and two young children. He left the company, and Sabel took over Manganiello’s duties as chairman and chief executive officer.
Manganiello founded NEOPS in June 1998, establishing its first office much closer to home, in Branford, Connecticut. Today, NEOPS has 37 offices in five states and 155 employees, including 77 clinicians—40 percent of whom are women. It is the second-largest O&P patient-care company in the country, after Hanger, and the largest independent O&P provider in the nation. The company also is involved in compression care, providing both products and therapeutic services to those with lymphedema, deep vein thrombosis, and other vascular disorders. Compression care accounts for nearly 10 percent of NEOPS’s business.
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Manganiello’s connection to Hanger entered a new chapter two years ago, when McCarthy “Mac” Hanger, CP—great-grandson of James Edward Hanger, who founded J.E. Hanger in 1862—joined NEOPS as chief operating officer. Today, Mac Hanger is the only member of the Hanger family still involved in the O&P field (although, he says, his son is interested in the business). “After purchasing Hanger from 39 shareholders, most of whom were Mac’s relatives, it’s amazing Andrew Carroll, CO, of the East Hartford office, to have Mac working with me now,” poses with a patient in a back brace. says Manganiello. “It has completed the circle.” they are due,” says Manganiello, “and Also part of NEOPS’s management we’ve been doing that since we started. team are Tom Whalen, chief adminIt makes suppliers be responsive and istrative officer; Richard Sokolowski, take us very seriously. These close CPA, chief financial officer; and Sara relationships allow us to help each other Colwick, CP, chief compliance officer. both technically and financially.” “We are very proud that we have cliniManganiello is a proponent of cians on our senior management staff,” giving back to the O&P field, and says Manganiello, which, in addition NEOPS trains many residents through a to Hanger (a CO) and Colwick, program with the National Commission includes the director of information on Orthotic and Prosthetic Education. systems, Darren Donnelly, who is a Manganiello is on the AOPA board of CO. Each term, the branch managers directors, keeping him in touch with the elect one of their own to serve on the industry as a whole. board of directors. NEOPS brings together clinicians The company, which tries to keep from several different offices on a most fabrication in house, has two regular basis to work with patients, central fabrication facilities—one in and managers often call each other for Massachusetts and one in Connecticut. problem solving. The company has NEOPS often serves as a beta two meetings each year for all clinitesting site for new technology. This cians, offering educational seminars year, for example, the company was and the opportunity to share ideas and the sole New England distributor of information. a myoelectric limb orthosis called NEOPS is unusual in that each of MyoPro, which can help paralyzed its practice managers owns up to 20 stroke or accident victims regain some percent of their business. “Having use of the arm. staff partners is very unusual for the “Because of the number of offices O&P industry, where most practices we have, we frequently get asked are small ‘mom and pop’ operations to become partners in new tech,” closely held by family owners. That says Hanger. model offers very little upside for NEOPS prides itself on having the staff, and the public company good relationships with its suppliers, model offers no opportunity for real including Southern Prosthetic Supply, ownership. Our model really is the best owned by Hanger, and Ottobock. of all worlds,” says Manganiello. “We “We believe in paying our bills before
O&P Almanac APRIL 2014
offer the security and sophisticated systems of a large company, the small, close family feel of a mom and pop, with real ownership. “This idea of 20 percent ownership structure actually came to me in a dream,” Manganiello says. He decided to offer the part-ownership plan after past experience at facilities where, he says, “We did well for ourselves. But the people who saw the patients, who did the work, didn’t get anything extra. I decided to set this up so it was shared, and it’s the best thing I ever did in my life.” “Because they are partners, they’re extremely motivated to be successful,” says Mac Hanger. “As a result, we’ve been able to retain some of the most successful people in the field. These people are some of the highest-level clinicians I’ve ever been involved with.” “We have no turnover,” says Manganiello. “Once they get here, they have every reason to stay.” Not only does ownership inspire dedication by practice managers, it gives them an opportunity to “unleash their entrepreneurial spirit,” says Hanger. “Prosthetists, orthotists, technicians, even office administrative staff, have a creative side, and they want to continue to develop more innovations and be as effective as they can. The structure that Ron dreamt of unleashed that power.” The company is clearly doing something right. According to Hanger, NEOPS experienced double-digit growth in each of the last two years, with no acquisitions. But, he says, “we are now in acquisition mode, and many people are coming to us because we offer safe harbor for them to practice sound, clinical O&P. Unlike a lot of the O&P field, we are not just surviving, but growing.” a Deborah Conn is a contributing writer to O&P Almanac. Reach her at debconn@ cox.net.
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AOPA National Assembly
New ways to advance the profession and your practice
ime pressures make it more and more challenging to accumulate the 75 continuing education (CE) learning credits required to secure your O&P recertification every five years. Now, the O&P Almanac has some easy-to-access solutions for you to earn as many as 32 business credits each year. The O&P Almanac is offering the opportunity to earn two business credits by reading the monthly Reimbursement Page column (page 16) and passing a brief online quiz— that’s 24 business credits each year. You also can earn two business credits by reading the new quarterly Compliance Corner column (page 32) and passing the quiz—that’s another eight business credits per year. Of course, many individuals in O&P earn their recertification by attending the AOPA National Assembly, where you can receive a combination of 32 business and clinical credits. With the event’s annual learning, networking, and product resourcing offerings, you could easily satisfy all of your continuing education needs in five years’ time. But even more options abound. AOPAversity’s online education also carries continuing credit hours, depending on the particular video offering that’s available to you. Like the O&P Almanac, this online resource is available 24/7. These credits can help fill the knowledge gaps of sessions you may have missed at the National Assembly or the recent World Congress. After all, you can’t be in two places at once when a session you want to attend is held at the same time as another must-attend.
Webcast Series Essential Coding & Billing Seminar The Essential Coding & Billing Seminar is yet another avenue to accumulate CE business credits. Given the contentious reimbursement environment, this two-day, must-attend event can help you earn 14 credits—and can help improve your billing knowledge tremendously. If it’s been a few years since you attended, you’ll find it a much changed learning experience keyed to the specific challenges you’re facing today with Recovery Audit Contractor audits and other reimbursement hurdles. In addition to the two AOPA staff professionals who present at the seminars, two experienced practitioners—John Naft, CPO, and Brian Gustin, CP—bring on-the-mark information from their experiences on front lines of operating their own O&P facilities. Then there are the monthly audio conferences, giving you the chance to earn one and a half CE credits by passing a short quiz. Offered at 1 p.m. EST, on the second Wednesday of each month, the audio conferences offer the advantage of providing education to an unlimited number of your associates on one line with the use of a speakerphone. Other 24/7 experiences include AOPA’s two webcast series: Mastering Medicare Coding & Billing Basic Principles and the Practice Management Series. Learn more about these programs at www.AOPAnet.org/education. a
APRIL 2014 O&P Almanac
Join the April and May Audio Conferences April 9: How to Use Advanced Beneficiary Notices Effectively The Advanced Beneficiary Notice (ABN) is a useful tool when used properly. Used incorrectly, it can result in unnecessary financial liability to providers. Join AOPA April 9 for an AOPAversity Mastering Medicare Audio Conference that will focus on how to use ABNs successfully, and why it’s an important part of your business operation. The following topics will be covered: • When an ABN is required and when it is not • How to properly execute an ABN • Why routine use of ABNs is not allowed • What modifiers to use when obtaining an ABN • How to communicate effectively with patients regarding ABNs • How to avoid common ABN pitfalls AOPA members pay just $99 ($199 for nonmembers), and any number of employees may listen on a given line. Participants earn 1.5 continuing education credits by returning the provided quiz within 30 days and scoring
O&P Almanac APRIL 2014
Learn how the modifiers affect your claims, and learn to use them properly to avoid potential claim denials. Join AOPA May 14 for an AOPAversity Mastering Medicare Audio Conference that will focus on how to use modifiers. • What is the difference between the RA and RB modifiers? • Which modifier allows you to provide services to a patient under hospice care? • What is the true meaning of the KX modifier? Answers to these questions and many others will be discussed during the call.
at least 80 percent. Contact Devon Bernard at dbernard@ AOPAnet.org or 571/431-0854 with content questions. Register online at http://bit.ly/aopa2014audio. Contact Betty Leppin at bleppin@AOPAnet.org or 571/431-0876 with registration questions.
E! QUIZ M
Read the O&P Almanac and Earn CE Credits!
Because of the highly educational content of the O&P Almanac’s Reimbursement Page and Compliance Corner columns, O&P Almanac readers can now earn two business continuing education credits each time you read the content and pass the accompanying quizzes. It’s easy, and it’s free. Simply read the Reimbursement Page column (appearing in each issue) and Compliance Corner column (appearing quarterly), take the quizzes, and score a grade of at least 80 percent. AOPA will automatically transmit the information to the certifying boards on a quarterly basis.
May 14: Modifiers: How and When to Use Them
Credits Easy & free!
Find the digital edition of O&P Almanac at www.aopanet. org/publications/digital-edition/. Find the archive at http:// issuu.com/americanoandp. The January 2014 quizzes are located at: https://aopa. wufoo.com/forms/op-almanac-jan-2014-reimbusement-page/ and https://aopa.wufoo.com/forms op-almanac-jan-2014compliance-corner/. The February 2014 quiz is located at: https://aopa.wufoo. com/forms/op-almanac-feb-2014-reimbursement-page/. The March 2014 quiz is located at: https://aopa.wufoo. com/forms/op-almanac-mar-2014-reimbursement-page/. And be sure to read the Reimbursement Page and Compliance Corner articles in this issue and take the April 2014 quizzes, available soon.
Mastering Medicare: AOPA’s Advanced Coding & Billing Techniques April 7-8: Bally’s Las Vegas Hotel & Casino June 12-13: Sheraton Boston Hotel
one-hour webcasts. Register for the webcasts on AOPA’s homepage.
Join your colleagues April 7-8 at Bally’s Las Vegas Hotel & Casino or June 12-13 at the Sheraton Boston Hotel for AOPA’s Mastering Medicare: Advanced Coding & Billing Techniques seminar. AOPA experts will provide 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 and much 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. Basic material that was contained in AOPA’s previous Coding & Billing seminars has been converted into nine
Las Vegas: AOPA has reserved a block of hotel rooms at Bally’s Hotel & Casino. Hotel reservations can be made by calling 702/967-4111. Register online for the April Las Vegas seminar at http://bit. ly/aopa2014lasvegas. Boston: AOPA has reserved a block of hotel rooms at the Sheraton Boston Hotel at the rate of $199 per night for reservations made before May 21, based on availability. Hotel reservations can be made by calling 617/236-2000. Register online for the Boston seminar at http://bit.ly/ aopa2014boston. Questions? Contact Devon Bernard at dbernard@aopanet. org or 571/431-0854.
AOPA’s 2014 Coding Products are Available in the Bookstore 2014 Illustrated Guide This easy-to-use reference manual provides an illustrated guide to the coding system in use for orthotics, prosthetics, and shoes, including HCPCS codes, official Medicare descriptors, and illustrations.
2014 Coding Pro The Coding Pro is O&P’s comprehensive guide to Medicare codes, reimbursement, and medical policies. This is the singlesource reference for all of your coding needs! The Coding Pro CD-ROM provides updated Medicare fee schedules for all 50 states and allows you to customize and import other fee schedules used by your office. Illustrations of the codes allow you to quickly sort codes. And writing prescriptions just got easier with the prescription writing tool. Network Version for use on multiple office terminals.
2014 Quick Coder Stop searching through numerous pages to find a code! AOPA’s redesigned Quick Coder provides a speedy reference to the HCPCS orthotic, shoe, and prosthetic codes and modifiers. These laminated cards are durable, longlasting, and convenient to store.
2014 Coding Suite Save $50 when you purchase the newly updated Coding Suite, which includes all of the coding products discussed above: 2014 Illustrated Guide, 2014 Coding Pro (Single-User CD Software), and the 2014 Quick Coder.
Go to the AOPA Bookstore and order your Coding Products today; visit http://bit.ly/BookStoreAOPA.
APRIL 2014 O&P Almanac
Action Needed: Senate To Vote on O&P Master’s Expansion Resources AOPA is pleased that S 1982, a comprehensive veterans’ bill, may be scheduled for debate. Section 322 of the bill would authorize the Veterans Administration to provide $10 million to create new accredited master’s degree programs in O&P or to expand existing O&P programs. With substantial numbers of experienced clinicians eligible for retirement, we must expand the pipeline of graduates with the master’s degrees that are now required for entry-level clinical positions. It is vital that senators understand the importance of this section before they vote on the bill, and that representatives agree to these provisions in subsequent House/Senate negotiations. Ask your members of Congress to support expansion of advanced education in O&P.
New Business Education Programs for 21st Century Entrepreneurs:
FREE Survive and Thrive— Bottom-Line, Profit-Oriented Business Programs for O&P If you missed the 2013 O&P World Congress, don’t let this opportunity to participate in these important programs pass you by: • Everything You Need to Know to Survive RAC and Prepayment Audits in a Desperate Environment • Competitive Bidding: Devastation to Orthotic Patient Care, Or Just a Passing Storm? • Food and Drug Administration Compliance for Patient-Care Facilities, Manufacturers, and Distributors • Your Mock Audit: Are You Ready for the Auditor to Examine Your Claims Record? 40
O&P Almanac APRIL 2014
You and your staff can now have a private viewing of business saving strategies and earn continuing education credits at the same time. Learn more about each session by visiting http://bit. ly/CreditCEpromo. AOPA members just $59 per session ($99 per session for nonmembers), and the price covers your entire staff. Take advantage of a special offer to buy three, get one free. Review the videos as many times as you like. Register at http://bit.ly/aopabusiness. Contact Betty Leppin at bleppin@ AOPAnet.org or 571/431-0876 with any questions.
Log On to AOPAversity Online Meeting Place for Free Education does not get any more convenient than this. Busy professionals need options––and web-based learning offers sound benefits, including 24/7 access to materials, savings on travel expenses, and reduced fees. Learn at your own pace—where and when it is convenient for you. For a limited time, AOPA members can learn and earn for FREE at the new AOPAversity Online Meeting Place: www.AOPAnetonline.org/education. Take advantage of the free introductory offer to learn about a variety of clinical and business topics by viewing educational videos from the prior year’s National Assembly. Earn continuing education credits by completing the accompanying quiz in the CE Credit Presentations Category. Credits will be recorded by ABC and BOC on a quarterly basis.
Follow AOPA on Facebook and Twitter Follow AOPA on Facebook and Twitter to keep on top of latest trends and topics in the O&P community. Signal your commitment to quality, accessibility, and accountability, and strengthen your association with AOPA, by helping build these online communities. • Like us on Facebook at: www.facebook.com/AmericanOandP with your personal account and your organization’s account! • Follow us on twitter at: @americanoandp, and we’ll follow you, too! Contact Steve Custer at scuster@ AOPAnet.org or 571/431-0835 with social media and content questions.
AOPA also offers two sets of webcasts: Mastering Medicare and Practice Management. • Mastering Medicare: Coding & Billing Basics: These courses are designed for practitioners and office staff who need basic to intermediate education on coding and billing Medicare. • Practice Management: Getting Started Series: These courses are designed for those establishing a new O&P practice. Register online by visiting http://bit.ly/WebcastsAOPA.
If You’re Paying More Than 1.9%, You’re Paying Too Much AOPA has partnered with Bank of America Merchant Services to offer credit card processing rates as low as 1.9 percent to AOPA members. Many members are paying more than 2.5 percent, and if you’re handling $500,000 a year in credit card transactions, the 0.6 percent savings is like getting a 200 percent return on your membership dues investment. To enroll, contact 888/317-5402 or email email@example.com. AOPA encourages members to request an audit of a recent processing statement to identify the savings they would enjoy.
Coding Questions Answered 24/7 AOPA members can take advantage of a “click-of-the-mouse” solution available at LCodeSearch.com. AOPA supplier members provide coding information about specific products. You can search for appropriate products three ways––by L code, by manufacturer, or by category. It’s the 21st century way to get quick answers to many of your coding questions. Access the coding website today by visiting www.LCodeSearch.com. AOPA’s expert staff continues to be available for all coding and reimbursement questions. Contact Devon Bernard at dbernard@AOPAnet.org or 571/431-0854 with content questions.
24/7 APRIL 2014 O&P Almanac
Welcome new members! The officers and directors of the 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
Braceworks Custom Orthotics Inc. practitioner who qualifies that patient-care facility for membership according to AOPA’s bylaws. Affiliate members do not require a certified or state-licensed 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: Level 1: equal to or less than $1 million Level 2: $1 million to $1,999,999 Level 3: $2 million to $4,999,999 Level 4: more than $5 million.
Bluegrass Bracing Inc.
1119 Colorado Avenue, Ste. 104 Santa Monica, CA 90401 800/496-0987 Category: Supplier Level 1 Member Jacob Karp
P.O. Box 1991 Lexington, KY 40588-1991 859/266-5500 Category: Patient-Care Member Kim Isaacs
Aselage Orthotic Services
Boston Brace International Inc./dba NOPCO
1001 Louisiana, Ste. 304 Corpus Christi, TX 78404 361/854-2355 Category: Patient-Care Member Carol Aselage
3700 State Route 33, Ste. LL02 Neptune, NJ 07753 732/481-4500 Category: Supplier Affiliate Member John Shimku, CO
1, 3500-24 Avenue NW Calgary, AB T2N 4V5 Canada 403/240-9100 Category: International Member Nancy Schneider, BCom
Orthocraft Inc. 1477 E. 27 Street Brooklyn, NY 11210 718/951-1700 Category: Patient-Care Member Hreschel Sauber a
Is Your Facility Celebrating a Special Milestone This Year? O&P Almanac would like to celebrate the important milestones of established AOPA members. To share information about your anniversary or other special occasion to be published in a future issue of O&P Almanac, please email firstname.lastname@example.org.
The premier meeting for orthotic, prosthetic, and pedorthic professionals
Mandalay Bay Resort and Casino Las Vegas, Nevada
Experience the energy—attend the country’s oldest and largest meeting for the orthotics, prosthetics, and pedorthic profession.
Energize your staff—ask about group discounts and space for your company to hold their own corporate meeting in conjunction with the Assembly.
The 2014 National Assembly education program will feature a learning program tailored specifically to meet your needs with programs to teach you the latest technology, best business practices, premier patient care through case studies, symposia, instructional courses, manufacturers workshops, panel discussions, live demonstrations, and fun networking events.
There is a reason why more O&P professionals attend the National Assembly than any other national meeting.
Visit www.AOPAnet.org for information and updates.
Sept. 4–7, 2014
O&P Almanac APRIL 2014
CLINICAL | BUSINESS | TECHNOLOGY
Products. Services. Networking.
Next Generation Accent foot from College Park The Accent® foot from College Park now comes in larger sizes and higher weight limits. The foot provides a service-free option for individuals who desire a cosmetically appealing foot with an easy-to-adjust heel height.
Features include: • NEW: Sizes 27 cm and 28 cm • NEW: Weight limits up to 250 lbs • 2-in (51-mm) user-adjustable heel height • Dynamic pylon and integrated pyramid options • Ankle fairing for superior finishing • Sandal-toe foot shell, with narrow and wide width options • Three firmness choices
4-Way Stretch Shrinkers from PEL Supply New Knit-Rite 4-Way Stretch Shrinkers, available from PEL, feature multidirectional stretch for improved fit and comfort. Additionally, the new shrinkers are extremely soft and easy to don. Featuring Knit-Rite’s core-spun construction, they not only provide a wider range of stretch, but have a dot silicone suspension band to help keep the shrinker in place. Above-knee versions also are available with a waistbelt. The new shrinkers are available with either Medium (20-30 mmHg) or Heavy (30-40 mmHg) compression, in transtibial or transfemoral versions. Plus, a new Extra Large AK Compressogrip accommodates up to 40 in (102 cm). Standard shrinkers are white, while the black shrinker features X-Static® fibers to prevent odors and provide wicking and thermal properties. Call PEL at 800/321-1264, or email customerservice@ pelsupply.com. a
For more information, call 800/728-7950 or visit www. college-park.com.
UPS Savings Program AOPA Members now save up to 30% on UPS Next Day Air® & International shipping! Sign up today at www.savewithups.com/aopa! Take advantage of special savings on UPS shipping offered to you as an AOPA Member. Through our extensive network, UPS offers you access to solutions that help you meet the special shipping and handling needs, putting your products to market faster. AOPA members enjoy discounts for all shipping needs and a host of shipping technologies. Members save: • Up to 30% off UPS Next Day Air® • Up to 30% off International Export/Import • Up to 23% off UPS 2nd Day Air®
al i c e Sp s! ng savi
All this with the peace of mind that comes from using the carrier that delivers outstanding reliability, greater speed, more service, and innovative technology. UPS guarantees delivery of more packages around the world than anyone, and delivers more packages overnight on time in the US than any other carrier. Simple shipping! Special savings! It’s that easy!
APRIL 2014 O&P Almanac
Find your region on the map to locate jobs in your area.
- Northeast - Mid-Atlantic - Southeast - North Central - Inter-Mountain - Pacific
Classified rates Classified advertising rates are calculated by counting complete words. (Telephone and fax numbers, email, and Web addresses are counted as single words.) AOPA member companies receive the member rate. Member Nonmember Words Rate Rate 50 or fewer words $140 $280 51-75 words $190 $380 76-120 words $260 $520 121 words or more $2.25 per word $5.00 per word Specials: 1/4 page, color 1/2 page, color
$482 $678 $634 $830
Advertisements and payments need to be received approximately one month prior to publication date in order to be printed in the magazine. Ads can be posted and updated at any point on the O&P Job Board online at jobs.AOPAnet.org. No orders or cancellations are taken by phone. Ads may be faxed to 571/431-0899 or emailed to scuster@ AOPAnet.org, along with a VISA or MasterCard number, the name on the card, and the expiration date. Typed advertisements and checks in U.S. currency made out to AOPA can be mailed to P.O. Box 34711, Alexandria, VA 22334-0711. Note: AOPA reserves the right to edit Job listings for space and style considerations. Responses to O&P box numbers are forwarded free of charge. Company logos are placed free of charge. Job board rates Visit the only online job Member Nonmember board in the industry at Rate Rate jobs.AOPAnet.org! $80 $140
Be served a bigger
slice of the pie!
dollar of of the 3.5 billion AOPA Find your slice begin with an O&P business— opportunity today! advertising
American Orthotic Promoting O&P
Jan. 1, 2014
DISCOVER more AOPA advertising opportunities. Call Bob Heiman, Advertising Sales Representative, at 856/673-4000 or email email@example.com
MediA AOPA 2014
O&P Almanac APRIL 2014
North Central CPO or Board-Eligible CPO Traverse City, Michigan We are seeking a motivated CPO or board-eligible CPO for our Traverse City location. Teter O&P is a privately owned company with 20 locations in Michigan. We offer a competitive salary, good benefits, and paid continuing education. If quality of life is important, you won’t be disappointed with us or a beautiful area to live in. Please send resume to:
Todd Stone, CPO 1225 W. Front Street Traverse City, MI 49684 Fax: 877/218-1947 Email: firstname.lastname@example.org
Job Opportunity CPO/BOCPO At Center for Orthotic & Prosthetic Care (COPC) our staff of orthotic and prosthetic professionals is committed to our mission of providing the highest level of patient care possible. COPC is a private partnership that enjoys the privilege and challenge of serving in leading and renowned medical centers in Kentucky, Indiana, North Carolina, and New York. Due to an opening at a new patient-care facility in Paducah, Kentucky, we are seeking a CPO, or Kentucky-licensed BOCPO, with a minimum of five years’ clinical experience. Because we have experienced rapid growth at our patient-care facilities in the Binghamton, New York, area, we are seeking a CPO/BOCPO with a minimum of two years’ experience. Candidates must possess excellent communication, organizational, and interpersonal skills, and the demonstrated ability to provide the highest quality patient care. These positions offer a competitive salary, relocation assistance, and excellent benefits including medical, dental, disability, 401K, certification and licensure fees, and continuing education expenses. If you meet these requirements and have an interest, please submit your resume, in confidence, to:
For the Paducah, Kentucky, position, via fax at 502/451-5354 or via email to email@example.com. For the Binghamton, New York, position, via email to firstname.lastname@example.org.
CALENDAR JOBS AMERICAN ORTHOTIC & PROSTHETIC ASSOCIATION (AOPA)
Member Beneﬁts North Central CO/CPO/C.Ped
Melissa Filippis Wright & Filippis 2845 Crooks Road Rochester Hills, MI 48309 Phone: 248/829-8335 Email: email@example.com
Experience the Benefits of AOPA Membership
Experience the Beneﬁts of AOPA Membership
Challenging RAC and CERT audit policies implemented by overly aggressive CMS contractors is AOPA’s number one priority. We have ﬁled litigation against CMS seeking relief from the unfair and unauthorized actions of CMS, its RAC auditors, and DME MACs relating to physician documentation requirements, and the change in policy resulting from the “Dear Physician” letter.
The mission of the American Orthotic and Prosthetic Association is to work for favorable treatment of the O&P business in laws, regulation and services; to help members improve their management and marketing skills; and to raise awareness and understanding of the industry and the association.
Expert Reimbursement and
Cost-Effectiveness Research. The
changing of health is Coding Guidance. AOPA’s Membership inreim-AOPA is climate one ofcarethe moving to a patient driven process bursement specialists provide
Your Survival Advocacy in Washington. AOPA’s staff and the lobbying team bring years of healthcare knowledge and experience to the issues of O&P. AOPA’s efforts help assure equitable reimbursement policies in these uncertain ﬁnancial times to ensure quality patient care.
coding advice and keep you up-to-date on the latest Medicare quality standards, RAC and other audits, billing rules and regulations. Answers to all of your questions related to O&P coding, reimbursement and compliance—via telephone or email. Members have unlimited access to AOPA staff experts.
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Making Your Voice Connect. AOPA’s Annual Policy Forum brings O&P leaders to Washington to receive high level brieﬁngs and to E GUID E deliver the O&P story personally to MEMBER VALU rg/join their members of Congress. www.AOPAnet.o
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LCodeSearch.com, AOPA’s online coding resource, provides members with a one-stop, up-to-the minute coding reference available 24/7, from anywhere you connect to the Internet.
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n Orthotic services; audit of the America regulation and RAC and CERT The mission Challenging business in laws, ented by overly of the O&P to e treatment policies implem contractors is g skills; and for favorabl and marketin CMS aggressive management one priority. ion. s improve their the associat AOPA’s number to help member industry and litigation against unfair nding of the We have ﬁled relief from the CMS, ss and understa of CMS seeking raise awarene rized actions MACs and unautho h. The DME , and ectiveness Researccare is its RAC auditors n documenta• Cost-Eff of health relating to physiciaand the change changing climate driven process rsement and ents, Reimbu patient tion requirem • Expert moving to a ing more and more e. AOPA’s reimfrom the “Dear Coding Guidanc ts provide in policy resulting s to and is demand cost-effectivenes bursement specialis Physician” letter. evidence of and keep you s. AOPA has coding advice the latest Medicare measure outcome Advocacy in study by health up-to-date on s, RAC and other • Your Survival funded a major -DaVanzo proving ons. team Washington. quality standard care ﬁrm Dobsons of timely O&P rules and regulati and the lobbying AOPA’s staff healthcare knowlaudits, billing of your questions the same cost-effectivenes of all sepatients with bring years Answers to ce to the issues did treatment of coding, reimbur patients who can assure edge and experien related to O&P nce—via telephone diagnoses as efforts help t. AOPA treatmen of O&P. AOPA’s sement policies ment and complia s have unlimited receive the ﬁeld not to resources of equitable reimbur or email. Member aggregate the vital research that n ﬁnancial times staff experts. in these uncertai access to AOPA to conduct this cannot conduct. patient care. rms ensure quality AOPA’s online s individual ﬁ earch.com, • LCodeS Connect. , provides member Your Voice coding resource, up-to-the minute • Making Policy Forum ton AOPA’s Annual with a one-stop e available 24/7, leaders to Washing (Continued) brings O&P ngs and to coding referenc you connect to the brieﬁ level re to receive high story personally to from anywhe deliver the O&Pof Congress. Internet. s their member
“The most gratifying piece of what I do
every day is to get up early in the morning, get to the office and know that we are going to make a difference.” - Kevin Carroll, MS, CP, FAAOP
Competitive salaries/benefits, continuing education, leading edge technologies, management opportunities and even paid leaves to assist in humanitarian causes, all available through a career at Hanger Clinic. Join Hanger Clinic and make a difference today. To view available positions and apply online visit: www.hanger.com/careers or scan the QR code. 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. Residency Program Info, contact: Robert S Lin, MEd, CPO, FAAOP Director of Residency Training and Academic Programs, Hanger Clinic, Ph. 860.667.5304; Fax 860.666.5386.
funded a major study by health care ﬁrm Dobson-DaVanzo proving
cost-effectiveness of timely O&P in the future of your company. treatment of patients with the same
MIS SIO N
Michigan Wright & Filippis, a leader in the rehabilitative health-care field, currently has three open positions for dedicated and compassionate clinicians. The first two positions are for certified orthotists with pediatric experience and helmet experience (or wanting to develop these skills) in the Saginaw and Madison Heights areas. The third position is for a CO/CPO/C.Ped, in Kalamazoo, Michigan. Individuals striving to excel professionally and clinically, while being supported by outstanding clinical and operational teams, please apply. Competitive benefits package. To learn more about a career with Wright & Filippis, visit our website at www.firsttoserve.com/careers/. Accepted by:
diagnoses as patients who did not receive treatment. AOPA can aggregate the resources of the ﬁeld to conduct this vital research that individual ﬁrms cannot conduct.
2014 AOPA Annual Membership enrollment(Continued) is now open. Call 571/431-0876 to request an application form, or visit www.AOPAnet.org.
AVAILABLE POSITIONS CLINIC MANAGER
Jackson, MI Ardmore, OK Bartlesville, OK
Modesto, CA Reno, NV
Albuquerque, NM Brunswick, GA Burr Ridge, IL Columbus, OH Dayton, OH Enid, OK Grand Rapids, MI Gurnee, IL Macon, GA San Antonio, TX San Francisco, CA
Santa Rosa, CA St. Louis, MO Stratford, CT Thomasville, GA Tulsa, OK Westlake, OH Worcester, MA Springfield, IL Columbia, MO La Jolla, CA
Bronx, NY Evansville, IN Johnston, IA Kansas City, KS La Mesa, CA Lancaster, PA Modesto, CA
Salisbury, MD Stockton, CA Cincinnati, OH Somersworth, NH Wichita, KS Hammond, IN Bullhead City, AZ
Kalamazoo, MI St.Louis, MO
Waterville, ME Williamsport, PA
APRIL 2014 O&P Almanac
YEAR-ROUND TESTING BOC Examinations. BOC has year-round testing for all of its examinations. Candidates can apply and test when ready, receiving their results instantly for the multiplechoice and clinical-simulation exams. Apply now at http://my.bocusa.org. For more information, visit www.bocusa.org or email firstname.lastname@example.org.
www.bocusa.org ■ OnLIne Training Cascade Dafo Inc. Cascade Dafo Institute. Now offering a series of six free ABC-approved online courses, designed for pediatric practitioners. Visit www.cascadedafo.com or call 800/848-7332.
■ APRIL 2-4 AOPA 2014 Policy Forum. Washington, DC. Renaissance Hotel. April is Limb Loss Awareness Month— what better way to support the profession than to participate in the Annual Policy Forum with extended education on April 3-4. To register or for more information, visit www. AOPAnet.org. Contact Betty Leppin at 571/431-0876 or bleppin@AOPAnet.org.
APRIL 3-5 Georgia Society of Orthotists & Prosthetists 2014 Annual Meeting. Atlanta. Wyndham Atlanta Galleria. Optimize your meeting experience. This year, the program includes two hours of unopposed exhibit time on Friday as well as one hour and 30 minutes
CALENDAR RATES Telephone and fax numbers, email addresses, and websites are counted as single words. Refer to www.AOPAnet.org for content deadlines. Member Rate
25 or less................... $40..................................$50 26-50......................... $50..................................$60 51+................... $2.25 per word................$5.00 per word Color Ad Special: 1/4 page Ad.............. $482............................... $678 1/2 page Ad.............. $634............................... $830 BONUS! Listings will be placed free of charge on the Attend O&P Events section of www.AOPAnet.org. Send announcement and payment to: O&P Almanac, Calendar, P.O. Box 34711, Alexandria, VA 22334-0711, fax 571/431-0899, or email scuster@AOPAnet.org along with VISA or MasterCard number, the name on the card, and expiration date. Make checks payable in U.S. currency to AOPA. Note: AOPA reserves the right to edit Calendar listings for space and style considerations. For information on continuing education credits, contact the sponsor. Questions? Email scuster@AOPAnet.org. 46
O&P Almanac APRIL 2014
■ April 4 California Orthotic & Prosthetic Association: Southern California Educational Event. CSU Dominguez Hills O&P Program, Long Beach, 8 AM – 5 PM. While enjoying warm and sunny Southern California weather, learn about new products, patient-care trends, and how to run a more profitable O&P business. Approved for ABC/BOC CEUs. Contact 916/498-7778 or visit www. californiaoandp.com/education.
PROMOTE Events in the O&P Almanac
on Saturday. Visit www. georgiasop.com or contact Erik Peterson at 770/271-7540 for more information.
APRIL 7-8 AOPA: Essential Coding & Billing Seminar. Bally’s Hotel & Casino. Las Vegas. To register, contact Betty Leppin at 571/431-0876 or bleppin@ AOPAnet.org. ■
■ April 9 AOPAversity Audio Conference–How To Use Advanced Beneficiary Notices (ABNs) Effectively. Register online at http://bit. ly/aopa2014audio. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org.
■ APRIL 10-12 International African American P&O Coalition 2014 Annual Meeting & Scientific Conference. Montgomery, AL. Alabama State University. The 2014 meeting will expand to two full days of lectures, hands on demonstrations, and the annual meeting. Visit www. iaapoc.org to register or for more information.
■ APRIL 10-12 Texas Association of Orthotists & Prosthetists 2014 Annual Meeting & Scientific Sessions. Richardson, Texas. Hyatt Regency North Dallas. Special Compliance Boot Camp on April 10. Visit www.taop. org to register or for more information. ■ April 26-27 The Foot and Ankle: From Athletic to Decrepit. Fayetteville, NC. Focus on children and their feet, while supporting a good cause. Register at FootCentriconline. com. 16 credits. ■ May 1 ABC: Application Deadline for Certification Exams. Applications must be received by May 1, 2014, for individuals seeking to take the July and August 2014 ABC certification exams for orthotists, prosthetists, pedorthists, orthotic fitters, mastectomy fitters, therapeutic shoe fitters, orthotic and prosthetic assistants, and orthotic and prosthetic technicians. Contact 703/836-7114, email email@example.com, or visit www.abcop.org/certification. ■ May 12-17 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 orthotic and prosthetic technicians in 250 locations nationwide. Contact 703/8367114, email certification@abcop. org, or visit www.abcop.org/ certification. ■ May 14 AOPAversity Audio Conference–Modifiers: How and When To Use Them. Register online at http://bit. ly/aopa2014audio. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org.
■ MAY 30-31 Louisiana Association of Orthotists & Prosthetists 11th Annual Meeting. Shreveport, LA. Hilton Hotel & Shreveport Convention Center. Take advantage of this opportunity to join about 100 attendees from the Louisiana, Mississippi, Arkansas, and East Texas regions. The continuing education this year will include prosthetics, orthotics, pedorthics and mastectomy tracts. For more information, visit www.laop.org or contact Debney Brown at 504/464-5577. ■ JUNE 5-6 Delcam Orthotics Technology Forum. Chicago. Loyola University. Meetings will cover new technologies and processes designed to assist practitioners and laboratories in prescribing, designing, and manufacturing custom orthotic insoles. For more information, visit www.orthotics-technologyforum.com. ■ June 11 AOPAversity Audio Conference–The Self-Audit: A Useful Tool. Register online at http://bit.ly/aopa2014audio. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org.
■ July 9 AOPAversity Audio Conference–The OIG: Who Are They and Why Are They Important? Register online at http://bit.ly/aopa2014audio. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org.
■ September 10 AOPAversity Audio Conference–Urban Legends in O&P: What To Believe. Register online at http://bit. ly/aopa2014audio. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org.
■ August 13 AOPAversity Audio Conference–AFO/KAFO Policy: Understanding the Rules. Register online at http:// bit.ly/aopa2014audio. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org.
■ October 8 AOPAversity Audio Conference–Medicare Enrollment, Revalidation, and Participation. Register online at http://bit.ly/aopa2014audio. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org.
■ SEPTEMBER 4-7 97th AOPA National Assembly. Las Vegas. Mandalay Bay Resort & Casino. For more information, contact AOPA Headquarters at 571/431-0876 or info@ AOPAnet.org.
■ November 7 California Orthotic & Prosthetic Association: Northern California Educational Event. Hilton Garden Inn San Francisco/ Oakland Bay Bridge, Emeryville, 8 AM – 5 PM While overlooking the breathtaking San Francisco Bay, learn about new products, patient-care trends, and how to run a more profitable O&P business. Approved for
ABC/BOC CEUs. Contact 916/498-7778 or visit www. californiaoandp.com/education.
■ November 12 AOPAversity Audio Conference–Gifts: Showing Appreciation Without Violating the Law. Register online at http://bit.ly/ aopa2014audio. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org.
■ December 10 AOPAversity Audio Conference–New Codes and Changes for 2015. Register online at http://bit. ly/aopa2014audio. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org.
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O&P STUDY REVIEW GUIDE
AMERICAN BOARD FOR CERTIFICATION IN ORTHOTICS,
APRIL 2014 O&P Almanac
Reimbursement Page AOPA Answers
What To Make of Material Codes Answers to your questions regarding billing for ultralight material codes, and more
receives hundreds of queries from readers and members who have questions about some aspect of the O&P industry. 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 firstname.lastname@example.org.
I am receiving Medicare denials for the ultralight material codes (L5940L5960) when they are billed with preparatory base codes. I have reviewed the lower-limb prosthesis local coverage determination (LCD) and policy article, and these codes are not included in the list of codes that will be denied as not medically necessary when billed with an initial or preparatory prosthesis. Why is Medicare denying these codes?
For many years, policy stated that the ultralight material codes were only to be used to describe ultralight components of a prosthesis that did not include the socket. Effective with the policy article effective April 1, 2010, CMS reversed its opinion on the use of the ultralight codes, stating that they were only to be billed when material used in the fabrication of the socket was ultralight in nature. CMS also issued instructions to the Durable Medical Equipment Medicare Administrative Contractors around this time advising them to create a system of edits that only allowed codes L5940-L5960 to be billed in conjunction with definitive base procedure codes and socket replacement codes. These instructions are most likely the cause for the denial of the ultralight codes when billing a preparatory device. You are correct, however, that the current lower-limb prosthesis LCD and policy article do not prohibit billing for ultralight material when
O&P Almanac APRIL 2014
providing a preparatory base code. This fact establishes grounds for an appeal based on the argument that policy does not indicate that ultralight materials are not medically necessary when used in the fabrication of a preparatory prosthesis. You also may be seeing an increase in the denial of the ultralight codes based on medical necessity or lack of supporting documentation. Remember that for every code you are providing, you must have a justification for why you are providing it; just because you always use carbon fiber is not a medical necessity justification.
Can I bill for repairs to diabetic shoes?
Yes, you may bill for repairs to diabetic shoes using the code A5507. The diabetic shoe policy states, “Code A5507 is only to be used for not-otherwise-specified therapeutic modifications to the shoe or for repairs.” However, keep in mind that the A5507 does count toward the total number of inserts/modifications a patient is eligible to receive in a year. If the patient already has received all of his or her eligible inserts/modifications, the repairs billed with A5507 will be denied as noncovered; the cost of the repairs will be the patient’s responsibility.
Can I bill an upgrade feature for a mastectomy bra, when the bra is made of silk or has extra support built into the bra?
No, these types of features may not be billed as upgraded features because the policy says those types of features are built into the base code of the bra. The policy clearly states that bras “may be constructed of any material (e.g., cotton, polyester, or other materials), with any type or location of closure, any size, with or without integrated structural support (e.g., underwire).” a
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