The Magazine for the Orthotics & Prosthetics Profession
Postpandemic Reimbursement Predictions P.14
It’s Back! 2021 AOPA National Assembly Education Session Highlights
THE ROOT OF PAIN
UNDERSTANDING POSTAMPUTATION PAIN AND THE INVESTIGATIONS INTO NEW SOLUTIONS P.22
Updates From the National Supplier Clearinghouse P.32
EARN 4 BU SI NE SS CE CREDITS
P.15 & 33
This Just In: AOPA Policy Forum Prompts Call To Action P.16
YOUR CONNECTION TO
THE PREMIER MEETING FOR ORTHOTIC, PROSTHETIC, AND PEDORTHIC PROFESSIONALS.
#AOPA2021 R REGIST
O OPEN S
WAIT T ’ N A C WE YOU! TO SEE
EXCELLENCE in EDUCATION Prosthetic
Mark your calendars for September 9-11, 2021, for an ideal combination of top-notch education and entertainment at the 104th AOPA National Assembly in Boston, MA.
We ARE AOPA
We look forward to seeing you!
ADVOCACY | RESEARCH | EDUCATION
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MAY 2021 | VOL. 70, NO. 5
DEPARTMENTS | COLUMNS
22 | The Root of Pain
Views From AOPA Leadership......... 4
Residual limb pain, phantom limb pain, and sound-side and back pain are all challenges experienced by some limb loss patients postamputation. Read about recommended interventions and promising research to help patients manage or reduce different types of pain. By Christine Umbrell
Charting a path forward How to reach staff
At-a-glance statistics and data
Research, updates, and industry news
People & Places........................................ 12
Transitions in the profession
Reimbursement Page.......................... 14 Gazing Into the Crystal Ball
16 | This Just In
Advocating for Patients During the Policy Forum—and Beyond More than 150 O&P advocates turned to online engagement to push for the Medicare O&P Patient-Centered Care Act during the 2021 Policy Forum last month. Participants convened for AOPA-led training and information sessions before meeting with nearly 150 members of Congress and their staffers.
28 | Reconnect, Recharge, 2021 SAVE THE 2021 DATES
Five predictions for the postpandemic O&P environment
Opportunity to earn up to two CE credits by taking the online quiz.
Compliance Corner............................... 32
Updates from the National Supplier Clearinghouse Opportunity to earn up to two CE credits by taking the online quiz.
Member Spotlight................................. 38 n n
Cypress Adaptive Fourroux Prosthetics
and Refresh Your Knowledge Preview can’t-miss education sessions from the upcoming AOPA National Assembly, where O&P professionals will meet in-person in Boston September 9-11 or view sessions virtually one week later.
AOPA advocacy, announcements, member benefits, and more
Marketplace............................................. 44 Careers........................................................ 48
PRINCIPAL INVESTIGATOR Cody L. McDonald, PhD, MPH, CPO........ 34 Meet a researcher from the University of Washington who recently studied the global prevalence of traumatic limb amputation and conducted a pilot study to explore information sharing among faculty in O&P. 2
MAY 2021 | O&P ALMANAC
Ad Index....................................................... 49 Calendar..................................................... 50
Upcoming meetings and events
State By State........................................... 52
Illinois, Kansas, Michigan, New York, Texas, and Washington
YOU ONLY NEED ONE REASON, REALLY. BUT IN CASE YOU NEED MORE, THERE ARE 40
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VIEWS FROM AOPA LEADERSHIP
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Post-COVID AOPA, Here’s What You Can Expect
UMMERS OFTEN REPRESENT a change in rhythm—from structured school days to “free time,” and from routine work schedules to balancing patient calendars and vacations. For AOPA, this summer will likewise be an exciting season of opportunity as we undertake extensive research to understand the best ways to serve you and our mission. I’m eager to share that we, the AOPA Board of Directors and staff, recently commissioned an independent group to carry out research among members and nonmembers so that we can ensure we give voice to the O&P profession and our position within healthcare. I’m energized by the implications of this research—not only because I love data … which I do … but because having this scale and scope of information from you means we can make even more informed, confident decisions based on the collective expertise and experiences you represent. It’s one important piece of our overall strategic planning for the next three to five years, and everything is under consideration, including our strategic initiatives, work plans, governance structure, organizational structure, and ways to improve recognition of the profession among payors and government agencies. Our goal is to create a path forward for the O&P community that is inclusive, credible, representative, and respected within healthcare. The insights will help us develop a strategic roadmap that can be reviewed and refined to guide future leadership and meet the needs of membership as they evolve. In that way, it’s not only about our immediate plans and strategy in the coming year. It’s forward-looking. It’s a tool for you, for us as a profession, and for those who will come after us. I look forward to learning more from this project, and we will share the findings later this year. I also want to make sure you know that we will host the AOPA National Assembly in Boston this year, September 9-11. In this issue, you’ll find some early details that may help as you make plans to join us. In the meantime, I hope you’ll enjoy a steady rhythm in your day-to-day work in the coming months. On behalf of the board, thank you for your hard work and partnership.
Traci Dralle, CFm, is president of AOPA.
We ARE AOPA
ADVOCACY | RESEARCH | EDUCATION 4
MAY 2021 | O&P ALMANAC
Board of Directors OFFICERS President Traci Dralle, CFm Fillauer Companies, Chattanooga, TN President-Elect Dave McGill Össur Americas, Foothill Ranch, CA Vice President Teri Kuffel, JD Arise Orthotics & Prosthetics, Spring Lake Park, MN Immediate Past President Jeffrey Lutz, CPO Hanger Clinic, Lafayette, LA Treasurer Rick Riley O&P Boost, Bakersfield, CA Executive Director/Secretary (Nonvoting) Eve Lee, MBA, CAE AOPA, Alexandria, VA DIRECTORS Jeffrey M. Brandt, CPO Ability Prosthetics & Orthotics Inc., Exton, PA Mitchell Dobson, CPO, FAAOP Hanger, Austin, TX Elizabeth Ginzel, MHA, CPO Baker O&P, Fort Worth, TX Kimberly Hanson, CPRH Ottobock, Austin, TX John “Mo” Kenney, CPO, LPO, FAAOP Kenney Orthopedics, Lexington, KY Linda Wise WillowWood, Mount Sterling, OH James O. Young Jr., LP, CP, FAAOP Amputee Prosthetic Clinic, Tifton, GA Shane Wurdeman, MSPO, PhD, CP, FAAOP(D) Research Chair Hanger Clinic, Houston Medical Center, Houston, TX
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American Orthotic & Prosthetic Association (AOPA) 330 John Carlyle St., Ste. 200, Alexandria, VA 22314 AOPA Main Number: 571/431-0876 AOPA Fax: 571/431-0899 www.AOPAnet.org
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Our Mission Statement Through advocacy, research, and education, AOPA improves patient access to quality orthotic and prosthetic care.
Our Core Objectives AOPA has three core objectives—Protect, Promote, and Provide. These core objectives establish the foundation of the strategic business plan. AOPA encourages members to participate with our efforts to ensure these objectives are met. EXECUTIVE OFFICES
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Tina Carlson, CMP, senior director, membership, education, and meetings, 571/431-0808, tcarlson@AOPAnet.org Akilah Williams, MBA, SHRM-CP, senior manager for finance, operations, and HR, 571/431-0819, awilliams@AOPAnet.org COMMUNICATIONS, MEMBERSHIP & MEETINGS Joy Burwell, director of communications and membership, 571/431-0817, jburwell@AOPAnet.org Betty Leppin, senior manager of member services, 571/431-0810, bleppin@AOPAnet.org Kelly O’Neill, CEM, manager of membership and meetings, 571/431-0852, kelly.oneill@AOPAnet.org Ryan Gleeson, CMP, assistant manager of meetings, 571/431-0836, rgleeson@AOPAnet.org Kristen Bean, membership and meetings coordinator, 571/431-0876, kbean@AOPAnet.org AOPA Bookstore: 571/431-0876
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MAY 2021 | O&P ALMANAC
Printing Sheridan SUBSCRIBE O&P Almanac (ISSN: 1061-4621) is published 10 times per year by the American Orthotic & Prosthetic Association, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314. To subscribe, contact 571/4310876, fax 571/431-0899, or email email@example.com. Yearly subscription rates: $59 domestic, $99 foreign. All foreign subscriptions must be prepaid in U.S. currency, and payment should come from a U.S. affiliate bank. A $35 processing fee must be added for non-affiliate bank checks. O&P Almanac does not issue refunds. Periodical postage paid at Alexandria, VA, and additional mailing offices. ADDRESS CHANGES POSTMASTER: Send address changes to: O&P Almanac, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314. Copyright © 2021 American Orthotic and Prosthetic Association. All rights reserved. This publication may not be copied in part or in whole without written permission from the publisher. The opinions expressed by authors do not necessarily reflect the official views of AOPA, nor does the association necessarily endorse products shown in the O&P Almanac. The O&P Almanac is not responsible for returning any unsolicited materials. All letters, press releases, announcements, and articles submitted to the O&P Almanac may be edited for space and content. The magazine is meant to provide accurate, authoritative information about the subject matter covered. It is provided and disseminated with the understanding that the publisher is not engaged in rendering legal or other professional services. If legal advice and/or expert assistance is required, a competent professional should be consulted.
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Perceptions of Patients With Disabilities Studies spotlight obstacles for individuals with disabilities
Individuals with mobility issues comprise a significant segment of the more than 61 million Americans living with disabilities. Many of these individuals face biases or misperceptions when seeking healthcare—even among healthcare providers.
PERCEPTIONS REPORTED BY PHYSICIANS
Report that people with significant disability have worse quality of life than nondisabled
Strongly agree that they welcome patients with disability into their practices
Feel confident about their ability to provide the same quality of care to people with disabilities
Strongly agree that the healthcare system often treats these patients unfairly
1 in 3
1 in 3
Do not have a usual healthcare provider
Have an unmet healthcare need because of cost in the past year
DISABILITIES AMONG CHILDREN
Number of U.S. children under 18 who had a disability in 2019
4.3 Percent Percentage of children who had a disability in 2019
0.6 Percent Percentage of children ages 5-14 with ambulatory difficulty
0.7 Percent Percentage of children ages 15-17 with ambulatory difficulty
DISABILITY IN THE UNITED STATES
26% Percentage of U.S. adults who have some type of disability
MAY 2021 | O&P ALMANAC
13.7% Percentage of U.S. adults who have mobility challenges
“More than 30 years after the Americans With Disabilities Act of 1990 was enacted, these findings about physicians’ perceptions of this population raise questions about ensuring equitable care to people with disability. Potentially biased views among physicians could contribute to persistent healthcare disparities affecting people with disability.” —“Physicians’ Perceptions of People With Disability and Their Healthcare,” Health Affairs, February 2021
SOURCES: “Physicians’ Perceptions of People With Disability and Their Healthcare,” Health Affairs, February 2021; “Childhood Disability in the United States: 2019,” U.S. Census Bureau; “Disability Impacts All of Us,” Centers for Disease Control and Prevention, September 2020.
HEALTHCARE ACCESS AMONG U.S. ADULTS, AGES 18-44, WITH DISABILITIES
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Happenings RESEARCH ROUNDUP
Army Scientists Develop Rate-Activated Tethers for Orthoses
MAY 2021 | O&P ALMANAC
Focusing on the mental effort of users operating prostheses, a research team from Johns Hopkins University and Drexel University is studying whether adding haptics, or an artificial sense of touch, to upper-limb prostheses reduces the mental effort required to operate the device. “Normally, vision is heavily used to successfully operate a myoelectric prosthesis, and this can cause high mental fatigue,” explained researcher Jeremy D. Brown, PhD, A study participant tests a prosthesis an assistant professor of featuring haptic feedback. mechanical engineering at Johns Hopkins. “Haptic feedback that whose stiffness were difficult to differsubstitutes for vision can reduce this entiate,” according to the researchers. cognitive load, which helps bridge the “This research suggests that future gap between the function of the healthy upper-limb prosthetic technologies limb and that of a prosthetic limb.” need to incorporate haptic feedback in Brown and his team proposed weartheir design,” said Brown. “In addition, able, wireless functional near-infrared this research provides a framework spectroscopy (fNIRS) neuroimaging for using brain imaging techniques to provide a continuous direct assesslike fNIRS to evaluate the cognitive ment of operator mental effort during load of new prosthetic technologies use of prostheses. Study participants in a variety of natural scenarios and were asked to differentiate objects in environments.” The findings were three distinct ways: using their natural published in April in IEEE Transactions hand; using a traditional myoelectric on Human Machine Systems. prosthesis without sensory feedback; Future projects for Brown’s team and using a myoelectric prosthesis with include investigating how haptic haptic (vibrotactile) feedback of grip feedback and automated grip control force. Results indicated that “discrimcan enable a prosthesis wearer to ination accuracy and mental effort are operate their prosthesis without visual optimal with the natural hand, followed observation. “An example scenario by the prosthesis featuring haptic would be the ability to watch TV while feedback, and then the traditional simultaneously picking up the TV prosthesis, particularly for objects remote out of view,” said Brown.
PHOTO: Courtesy of Jeremy Brown, Haptics and Medical Robotics Lab, Johns Hopkins University. All rights reserved.
U.S. Army researchers have debuted an orthotic device design that features adaptable coupling elements and rate-activated tethers incorporated into elastic materials, comprising the body of orthoses. The tethers are “cable-like devices that are filled with fluid and filaments,” according to an announcement from the DEVCOM Army Research Laboratory, and are made from materials that are both elastic and able to seal fluid inside, such as rubber, silicone, polymer, or latex. The filaments inside the tethers are made of steel, polymer, glass, or carbon; these filaments may be either free-floating or attached to one or both sides of the tethers. Orthoses made using the new design provide variable support, depending on the wearer’s speed and movement intensity. Because they can stretch and recover quickly during movement, they provide a unique balance of comfort, performance, and support, according to the research team. Used in an ankle brace, for example, the tethers will support regular daily activities without causing the joint’s weakening, but will limit motion during fast movement to prevent supination of the ankle, according to the researchers.
Researchers Study Benefits of Prostheses Integrated With Haptic Sensory Feedback
AHA Proposes Strategies To Decrease PAD Amputation Rates The American Hospital Association (AHA) has released a policy statement featuring recommendations to improve limb outcomes and drive U.S. amputations rates down 20 percent by the year 2030. Published in March in Circulation, the AHA statement, written by AHA Writing Committee Chair Mark A. Creager, MD, and his team, seeks to lower the number of Americans requiring amputation due to peripheral artery disease (PAD). Stakeholders, including clinicians, researchers, patients, family members, regulatory agencies, and the healthcare system, should work together to make appropriate changes “to take steps that will reduce the likelihood that someone with peripheral artery disease will progress to the point that they develop critical limb ischemia and need an amputation,” said Creager. The AHA offers several suggestions
for improving public awareness of PAD and increasing use of effective PAD management strategies, such as smoking cessation, use of statins, and foot monitoring/care in patients with diabetes. To facilitate the implementation of these recommendations, AHA proposes “several regulatory/legislative and organizational/institutional policies such as adoption of quality measures for PAD care; affordable prevention, diagnosis, and management; regulation of tobacco products; clinical decision support for PAD care; professional education; and dedicated funding opportunities to support PAD research.” The AHA statement notes that if the recommendations and proposed policies are implemented, “we should be able to achieve the goal of reducing the rate of nontraumatic lower-extremity amputations by 20 percent by 2030.”
Paralympic Games Will Feature Record Media Coverage
More than 290 athletes across 22 Paralympic sports are expected to represent Team USA in the Tokyo Paralympic Games August 24September 5. NBC Universal will air a record 1,200 hours of Paralympic coverage from the Tokyo Games, including the first NBC primetime broadcasts in history. NBC also will air U.S. Paralympics Trials coverage on June 27.
Academy Partners With OPAF To Provide Administrative and Support Services The American Academy of Orthotists and Prosthetists has announced a partnership with the Orthotic and Prosthetic Activities Foundation (OPAF). The Academy will provide administrative support to help OPAF fulfill its mission of serving those with physical and mobility challenges and raising public awareness of physical disability, limb loss, and limb difference. The partnership follows a July 2020 decision by the OPAF Board to enter a state of dormancy in light of the COVID-19 pandemic, to reduce operating costs and allow the board to focus on restructuring. Academy President Jared Howell, MS, CPO, FAAOP, said the Academy’s mission is “hand in glove” with OPAF’s:
“Many in the O&P community were deeply disturbed by the thought of there being no OPAF to serve the O&P patient population,” he said. “The Academy is thrilled to support the OPAF mission as it positively impacts the lives of the patients [that] we as O&P practitioners serve.” The partnership allows OPAF to remain as an independent 501(c)3, with a focus on fundraising and program
development, while the Academy will help administer the day-to-day operations of the OPAF financials, marketing, events, and website. “On behalf of the OPAF Board of Directors, we are so excited to announce our partnership and bring our programming back to the communities that we serve,” said Travis Young, CPO, president of OPAF. “Since its inception, OPAF has served as the philanthropic arm of the orthotic and prosthetic community, and we look forward to the expanded relationship with the Academy and the opportunities that it will bring. We are grateful for the support of all of our partners, instructors, and participants over the years and are thrilled for what the future holds.” O&P ALMANAC | MAY 2021
PEOPLE & PLACES PROFESSIONALS
ANNOUNCEMENTS AND TRANSITIONS
The Amputee Coalition named Mona Patel, founder and executive director of the San Antonio Amputee Foundation, and Chad Jerdee, most recently the global lead of responsible business for corporate sustainability and citizenship at Accenture, to its board of directors. The Coalition also appointed TaKeisha S. Walker as chief operating officer. “Our mission is to provide support, education, and advocacy to the more than 2 million Americans with limb loss and limb difference and the more than 28 million who are at risk for amputation,” said Amputee Coalition President and CEO Mary Richards. “Mona and Chad’s insights, lived experience, and leadership expertise will push us closer toward our achieving our strategic goals to grow the Coalition,” she added. “TaKeisha brings executive-level programmatic and organizational expertise that will propel the growth we need to steward our resources wisely in serving even more people living with limb loss and limb difference.” The Orthotic and Prosthetic Education and Research Foundation (OPERF) and the American Board for Certification in Orthotics, Prosthetics, and Pedorthics have announced the following individuals as recipients of the 2021 OPERF/ABC Student Award for Academic Achievement: Lynden Brown (Alabama State University), Samuel Byrne (Eastern Michigan University), Meghan Criswell (University of Washington), Megan D’Apice (California State University Dominguez Hills), Stasia Iwuc (Baylor College of Medicine), Emily Lipski (Baylor College of Medicine), Alexander Miller (International Institute of Orthotics and Prosthetics), Katherine Turnage (University of Washington), and Jaclyn Webster (University of Washington). In addition, three O&P residents were named as recipients of the Resident Travel Award: Kiley Armstrong, CO; Sheila Pack; and Samantha Stauffer, MSOP, CPO.
MAY 2021 | O&P ALMANAC
to our 2021 AOPA Supplier Plus Members for their continued support of the association.
AOPA 2021 SUPPLIER PLUS MEMBERS
For more information, contact Kelly O’Neill at 571-431-0852 or kelly.oneill@AOPAnet.org. FOLLOW US @AmericanOandP
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By JOSEPH MCTERNAN
Gazing Into the Crystal Ball What does a postpandemic environment look like for O&P?
Editor’s Note—Readers of Reimbursement Page are eligible to earn two CE credits. After reading this column, simply scan the QR code or use the link on page 15 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! QU IZ M EARN
MAY 2021 | O&P ALMANAC
F YOU ARE LIKE me, when you first
heard the words “coronavirus” and “COVID-19,” you thought they would cause a short-term inconvenience, and that life would return to normal after a few weeks. More than one year later, the world has changed forever. The COVID-19 public health emergency (PHE) has claimed millions of lives, and each step forward in battling the virus seems to be met with new setbacks, including variants of the virus and surges in infection rates. While the COVID-19 PHE is far from over, the introduction of effective vaccines and continued efforts to reduce the spread of disease have resulted in a little twinkle of light at the end of a long, dark tunnel. This month’s Reimbursement Page takes a look into the future to predict five things that may impact your O&P business in a postpandemic environment.
TPE Will Return
CMS acted quickly last spring to ensure that Medicare and Medicaid beneficiaries would continue to have access to effective and appropriate clinical care. Shortly after the PHE declaration, CMS announced significant relaxation of policy requirements to provide flexibility to providers and allow them to focus their efforts on caring for patients rather than chasing documentation. One of these flexibilities was an announcement of the suspension of audits for claims with dates of service during the COVID-19 PHE. This announcement resulted in the suspension of Medicare Target, Probe, and Educate (TPE) audits. The TPE program was implemented in 2018 and transformed the way many Medicare audits were handled. TPE audits are focused in scope and usually examine up to 20 claims at a time on a prepayment basis; they consist of up to three rounds of audit activity with individual, providerbased education after each TPE round. The intent of this process is to address incorrect billing practices and eliminate errors through education. Once a provider shows sufficient improvement in their billing practices, they may be moved out of the TPE process and exempt from future TPE audits for a defined period, usually at least one year. The TPE program has been successful and is very popular with providers, who enjoy fewer audits and increased education. Since TPE audits are always performed on a prepayment basis, they cannot be performed during the PHE. As a result, the TPE program has been formally suspended for the duration of
the COVID-19 PHE. Since the TPE program has proven to be very successful and is popular among Medicare contractors and providers, it is reasonable to assume that once the COVID-19 PHE is declared over, CMS will instruct its contractors to reinstitute the TPE program.
Telehealth Is Here To Stay
If you want to identify one positive development that came about because of the COVID-19 PHE, it would be the emergence of telehealth as a viable and efficient method to deliver high-quality, effective healthcare. While telehealth is not a new concept, Medicare rules have been historically restrictive when it comes to reimbursement for telehealth services—so much so that many providers have been discouraged from considering telehealth as a viable pathway to treat Medicare patients. The COVID-19 PHE forced Medicare and other payors to revisit policies regarding telehealth services in the interest of patient health and safety. As a result of the PHE, telehealth restrictions have been significantly relaxed to allow providers and patients to communicate effectively without having to be in the same location. Historically, telehealth rules have been fairly restrictive to ensure proper security as well as compliance with the Health Insurance Portability and Accountability Act; however, technology has advanced to the point where telehealth services can be coordinated through multiple delivery models that allow for delivery of effective healthcare in a secure setting. The successful use of telehealth services during the COVID-19 PHE will most likely result in significant changes to the prepandemic restrictions on the use of telehealth as a viable and accepted method to deliver effective healthcare.
RAC Audits Will Focus on Claims Made During the PHE
CMS has stated that claims with dates of service during the PHE are not subject to audit currently—but there has been no discussion about whether those claims will be subject to future
audits, including those performed by recovery audit contractors (RACs). CMS has provided significant flexibility regarding coverage policy requirements to ensure that Medicare patients have continued to have access to needed medical care during the PHE. Despite the relaxation of some of the requirements, it remains important to properly document general medical necessity to support claims that are paid by Medicare. RAC contractors are compensated based on their successful identification of Medicare overpayments and are paid a percentage of the money that is recouped based on their audits. RACs rely on identifying “low-hanging fruit” to maximize their profitability. It is a reasonable assumption that RAC contractors will be very interested in reviewing claims with dates of service during the PHE. While traditional policy requirements that were relaxed because of the COVID-19 PHE will not be subject to RAC review, the RACs may be able to identify scenarios where policy requirements that remained in effect during the PHE were not met, resulting in an overpayment determination by the RAC.
The Need for O&P Services May Increase
The COVID-19 PHE has resulted in the loss of millions of lives across the globe. What has yet to be realized is how the COVID-19 PHE has impacted the health of individuals for reasons not directly related to the coronavirus pandemic. Throughout the COVID-19 PHE, the provision of general healthcare has been affected, especially in rural and traditionally underserved areas. Whether caused by access issues or reluctance to seek care due to concerns about potential exposure, some individuals may have received fewer healthcare services than they would have outside of a global pandemic. The impact of this reduction in overall healthcare services may be more prevalent for patients who were already at risk for limb loss or limb impairment— and may ultimately lead to higher rates of amputation and increased episodes of conditions such as stroke and orthopedic conditions that may increase the need for orthotic intervention.
Since the COVID-19 PHE remains an active pandemic, it is difficult to quantify the impact it has had on the future need for O&P care—but it is a reasonable expectation that there will be some impact on at-risk patients.
Healthcare Integration Will Continue
The integration of the delivery of healthcare services is not a new trend. The impact of a significant global pandemic will most likely increase efforts of health systems to pursue integrated healthcare delivery as a strategy to reduce costs and increase efficiency. O&P has traditionally been considered a niche market when compared to the much larger healthcare universe; however, as major health systems look for new and innovative models to streamline their businesses, O&P may garner more attention. The integration of O&P business has seen a significant increase in recent years as the lines between patient care, distribution, and manufacturing become a little more blurred, but the impact of the COVID-19 PHE may bring more external resources into the mix as larger health systems look to increase their footprint beyond their traditional lines of business.
What Does the Future Hold?
None of the five predictions listed above are guaranteed, and the changing nature of the PHE may further impact any or all of these forecasts. Only one thing is certain: The impact of the COVID-19 PHE on healthcare worldwide will be significant and will result in permanent changes to healthcare delivery models. Joseph McTernan is director of reimbursement services at AOPA. Reach him at jmcternan@AOPAnet.org. Take advantage of the opportunity to earn two CE credits today! Take the quiz by scanning the QR code or visit bit.ly/OPalmanacQuiz. Earn CE credits accepted by certifying boards: www.bocusa.org
O&P ALMANAC | MAY 2021
This Just In
Advocating for Patients During the Policy Forum— and Beyond Practitioners, patients, and business owners convened remotely to push for the Medicare O&P Patient-Centered Care Act, with ongoing advocacy needed
NE HUNDRED AND FIFTY O&P
stakeholders met online to take part in the 2021 AOPA Policy Forum and focus on one “ask”: for legislators to support and sponsor the Medicare O&P Patient-Centered Care Act. O&P business owners, clinicians, patients, and related advocates participated in virtual meetings with nearly 150 members of Congress and their staffs April 20-22 and 27-29. During those meetings, stakeholders explained the need for the legislation—HR 1990 in the House of Representatives and awaiting a bill number in the Senate—before asking lawmakers for their support.
HR 1990 16
MAY 2021 | O&P ALMANAC
Policy Forum participants were optimistic after the meetings, reporting that many legislators and staffers agreed to consider sponsoring the legislation. However, new guidelines from the Committee on Rules in the House of Representatives recommend that new bills seek 100-120 co-sponsors before they are brought before committee. AOPA is asking that all O&P stakeholders—whether they were able to attend the Policy Forum or not—continue to contact members of Congress to ask them to co-sponsor HR 1990 and the Senate bill. For O&P professionals considering contacting their legislators, it’s important to understand the four key provisions that comprise the Medicare O&P Patient-Centered Care Act: differentiating O&P from durable medical equipment, restoring the original congressional definition of “minimal self-adjustment,” prohibiting drop shipping of devices that are not truly off-the-shelf, and exempting certified and/or licensed orthotists and prosthetists from competitive bidding.
This Just In
It also will be helpful during future legislative meetings to “educate legislators about the clinical services you provide and the patients you care for,” said Ashlie White, AOPA’s director of strategic alliances. She encouraged Policy Forum attendees to emphasize that “the Medicare O&P benefit should not be treated like DME and supplies in the statute and regulations.” HR 1990 was introduced to the House of Representatives in the 117th Congress on March 17 by Reps. Mike Thompson (D-California), Brett Guthrie (R-Kentucky), GK Butterfield (D-North Carolina), and GT Thompson (R-Pennsylvania). It is expected to be introduced in the Senate immediately following the Memorial Day Recess, with Sens. Mark Warner (D-Virginia), Steve Daines (R-Montana), Tammy Duckworth (D-Illinois), John Cornyn (R-Texas), and Chuck Grassley (R-Iowa) expected to introduce the bill at that time.
Tips for Virtual Legislative Meetings
During the opening session of the Policy Forum, experienced O&P advocates offered 10 tips for facilitating successful virtual meetings with members of Congress. These suggestions, shared by a group of Minnesota stakeholders who frequently advocate together, serve as helpful reminders for the O&P community as it continues to push for the Medicare O&P PatientCentered Care Act in upcoming meetings with legislators.
Be prepared. Dress for success, even in the virtual world, said Teri Kuffel, JD, vice president of Arise Orthotics & Prosthetics and AOPA vice president. She suggested calling or emailing the day before to confirm your appointment. Prior to the meeting, make sure your computer is set up with optimal video and audio capabilities, then choose an appropriate background for a Zoom call, “with no distractions such as bright lights, loud sounds, or busy backgrounds.”
AOPA is asking that all O&P stakeholders—whether they were able to attend the Policy Forum or not— continue to contact members of Congress to ask them to co-sponsor HR 1990 and the Senate bill.
Eve Lee , MBA, CAE, AOPA executive director
Joe McTernan, AOPA director of Ashlie White , MA, AOPA coding and reimbursement services, director of strategic alliances education, and programming
2. Do your homework. Review mate-
rials in advance and become “the expert in the room,” recommended Kuffel. For meetings centering on the current Medicare O&P PatientCentered Care Act, make sure you understand the four main provisions and are able to explain why they facilitate optimal O&P patient care. It’s also important to explain your issue in terms lawmakers will understand, without using O&P acronyms. “Realize that these decision makers really need to be educated; we need to explain to them what the device is, the functionality of the device, and the difference between an orthotic
and prosthetic,” said Aaron Holm, executive director of Wiggle Your Toes and manager of consumer marketing and engagement for Ottobock.
3. Select your spokespersons. Ideally, at least three O&P stakeholders will be involved in a legislative visit: a practitioner, a patient, and a policy/businessperson/student, said Kuffel. “Patients help educate and personalize the O&P issues; practitioners explain how access to care and devices can be challenged; and policy/business/students advocate” and clarify the impact of O&P intervention, she said.
Teri Kuffel, JD, AOPA vice president
O&P ALMANAC | MAY 2021
This Just In
meeting ahead of time, said Kuffel. It’s likely the staff member assigned to your call has a healthcare focus, so “try to establish a relationship with that staffer, and follow up afterward to keep the connection going,” said Kuffel. “Be comfortable, be excited, and be relatable.” “Don’t get discouraged if you’re meeting with a staffer,” added Holm. “Realize you are building a connection. In a couple of years, that staffer could be working for another legislator, or could become a legislator themselves.” Peter Thomas , NAAOP general counsel
“I can’t stress how important it is to bring someone with limb loss with you,” added Rob Rieckenberg, a Wiggle Your Toes board member and above-knee amputee since 2005. He recommends “showing your hardware” on screen—a more challenging feat virtually than in person, but helpful nonetheless, he said. Regardless of how many advocates are on hand, it’s important to plan ahead of time which individuals will take the lead on discussing the different points you plan to address.
4. Be brief and stay focused. Have
a short outline with you and stick to it, said Kuffel. Start with an ice breaker or hometown small talk; know your legislator’s party affiliation; find out if they are on a committee that is important to O&P; know your legislator’s recent voting record; and use specific bill numbers and share the names of the sponsors, said Kuffel. This background information can help you navigate the conversation and focus on the important issues.
5. Personalize your issues. Tell a
few stories about caring for your patients, and consider sharing how an unfair denial, audit, or
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appeal has had a negative impact on patients, suggested Kuffel, to demonstrate some of the challenges of providing access to O&P care and devices. For example, Rieckenberg said he often shares his experiences navigating insurance coverage and caps on prosthetic devices, and how he has had to fight for coverage as a person with limb loss. Stories such as these may resonate with legislators who have family members with limb loss or difference.
8. Close the deal, and remember
the ask. Be very clear regarding why you are participating in the meeting: Ask them to co-sponsor the bill; ask them to vote on the bill; ask for their support on future O&P-related issues; and ask them to take a photo, even if virtual, said Kuffel. In addition, “don’t hesitate to ask them if there’s anything they need from you,” added Holm, such as follow-up information or supporting documents that will help them support the issue at hand.
6. Be positive and react honestly.
Try to focus on the positive aspects of the O&P world because “our patients have remarkable stories and need our help,” said Kuffel. “Don’t be afraid to address some of the negatives, but try to sandwich them between the positives.” If you don’t know the answer to a question, be honest and say, “I’m not sure, but I can find out and get back to you.” And keep in mind that your legislator wants your vote and works as your advocate, said Kuffel.
7. Be friendly with the legislative
staff. Many legislative meetings are handled by staff members, rather than the legislators themselves. Find out with whom you are
Teri Kuffel, JD, Rob Rieckenberg, and other O&P advocates met with the staff of Sen. Tina Smith (D, Minnesota) during the AOPA Policy Forum.
9. Leave behind materials. For virtual meetings, you will have to email supporting documents that you would normally bring with you to in-person meetings, so be sure you have appropriate email contact information, suggested Kuffel. For legislative meetings centering
This Just In
on the Medicare O&P PatientCentered Care Act, leave-behind materials summarizing the legislation can be found on AOPA’s website at www.aopanet.org/ legislative-regulatory/2021virtual-policy-forum.
10. Say “thank you.” “Common cour-
tesies go a long way,” said Kuffel. “Remember to say ‘please’ and ‘thank you’” during the meeting, then follow up with email or written correspondence. Then, “stay in touch offseason” by touching base with your legislators at local parades and events, and proffer personalized invitations to legislators to tour your patientcare office. “Give them a reason to fly home to visit your facility,” said Holm. “They love to see individuals in their home states and post about it on their social media.”
As the O&P community continues to push for the Medicare O&P PatientCentered Care Act to improve access
Teri Kuffel, JD; Charles Kuffel, CPO; Eve Lee, MBA, CAE; and others met with a representative from Minnesota during the Policy Forum.
to quality orthotic and prosthetic services and devices for patients, more stakeholders should consider reaching out to legislators to engage in virtual meetings. After the pandemic, AOPA expects to return to the Hill in person—while continuing to facilitate some meetings virtually, as this method of communicating has
emerged as an effective form of advocacy. With both in-person and virtual meetings, “your impact is immediate,” said White. “Remember that we are all here to educate and advocate with purpose,” said Kuffel, “to provide access for our patients to orthotic and prosthetic care and devices.”
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r ip l
What prosthetists should know about postamputation pain—and the new studies that could impact future treatments By CHRISTINE UMBRELL
NEED TO KNOW • O&P professionals frequently encounter patients dealing with different types of pain, including residual limb pain, phantom limb pain, amputated-side-knee and sound-knee pain, and low-back pain. • Prosthetists play an important role in pain management by providing well-fitting sockets, optimal alignment of prostheses, and appropriate componentry selection. • Phantom limb pain appears to be closely related to residual limb pain, and is highly variable. Prosthetists can help educate patients about nonpharmacological strategies to minimize this type of pain, including shrinker socks, activity pacing, and mirror therapy. • Some lower-limb prosthesis users experience a significant “collision,” or impact, on their intact limb during gait, causing knee pain; solutions that focus on softening the landing or reducing the load could minimize pain. • Determining underlying causes of low-back pain and related issues may require referral to other healthcare providers, such as physical therapists, psychologists, or physicians specializing in pain management. • Researchers are currently studying phantom limb pain and neuromodulation; radiofrequency ablation for neuromas; and other novel techniques to minimize pain in the limb loss population.
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EOPLE with limb loss experience
many challenges beyond amputation—including management of “a number of different pain types,” says Phil Stevens, MEd, CPO, director of the Department of Clinical and Scientific Affairs at Hanger Clinic and adjunct faculty at Concordia St. Paul. “There is phantom pain, or pain in a body segment that is no longer present; residual limb pain; and pain secondary to overuse symptoms, either in the torso, upper back and shoulders, or within the sound-side extremity.” As part of the multidisciplinary care team, prosthetists offer a unique perspective to their patient’s long-term pain management. By recognizing the different types of pain and discomfort in patients, offering suggestions to help patients minimize or manage their pain, referring patients to other healthcare professionals when appropriate, and staying current on the latest research and new pain protocols under investigation, prosthetists can play a role in their patients’ overall rehabilitation.
Different types of amputations can lead to varying types of pain. Available evidence suggests that “persistent postoperative limb pain is 1.5 times more likely with upper-limb amputation,” says Stevens. Very few individuals with upper-limb amputation describe their situation as ‘pain-free.’” Upper-limb patients also are more likely to experience severe pain, at a greater frequency. “Roughly two-thirds of those with upper-limb amputation describe their pain as ‘moderate’ to ‘severe,’ compared to less than a third of those with lower-limb amputation,” says Stevens. “Almost all individuals with upper-limb amputation report pain on ‘most days’ or ‘every day,’ compared to about one-third of those with lower-limb amputation.”
Phil Stevens, MEd, CPO
Individuals with lower-limb loss may face different challenges. They experience low-back pain at up to four times the rate seen in the general population, according to Samantha Stauffer, MSOP, CPO, a clinician at Independence Prosthetics-Orthotics and a doctoral student in biomechanics and movement science at the Delaware Limb Loss Studies Lab at the University of Delaware. “On top of that, more than 50 percent experience phantom limb pain and/or residual limb pain,” she says. Chronic pain is associated with mood instability, limits in physical function, and reduced employment, says Stauffer. Andreas Kannenberg, MD (GER), PhD, executive medical director for Ottobock Healthcare LP in Austin, Texas, led a team that collected data on sound-knee pain, residual knee pain, and low-back pain in individuals
with unilateral transtibial amputation and K3 mobility. His team completed a cross-sectional study that compared the effect of different prosthetic feet on these types of pain with concurrent and recalled ratings. Of the 57 patients surveyed, only 7 percent did not report pain in any of three locations, according to Kannenberg. Fifty-three percent reported sound-knee pain, 44 percent reported residual knee pain, 61 percent reported low-back pain, and 28 percent reported pain in all three body regions of 3 or greater out of 10. “These numbers confirm that pain is a huge health issue in the population of individuals with lower-limb amputation,” Kannenberg says. He points to a wide array of contributing factors. Sound-knee and low-back pain may be caused by the reduced push-off of passive prosthetic feet, resulting in higher loads to the sound limb and knee as well as asymmetric activation of pelvic and trunk muscles that, over time, results in back pain, says Kannenberg. Amputated-side knee pain in transtibial amputees may be caused by increased mechanical stress to the knee due to the
lack of adaptation of feet with rigid ankle attachments to uneven walking surfaces, he adds.
Andreas Kannenberg, MD (GER), PhD
In addition, some amputees may suffer from local residual limb pain due to hypersensitivity, scar tissue, or even keloids, neuromas, ulcers, bone spurs at the amputation cut, conditions like ossifying myositis, and poor socket fit that stresses the soft tissue of the residual limb, explains Kannenberg. On the sound-limb side, “joint pain … is usually caused by increased mechanical stress as the sound limb takes over more weight-bearing than the amputated limb,” he says. “Reduced push-off of passive prosthetic feet is one contributor to that. If patients use walking aids, such as crutches, canes, or walkers, they may also suffer from overuse pain in joints of the upper limb, especially the shoulder, elbow, and wrist.”
O&P ALMANAC | MAY 2021
Phantom and Residual Limb Pain
Phantom limb pain, while complicated, is the most common pain experience for the limb loss population, according to Stevens. Phantom pain appears to be closely related to residual limb pain. “In other words, those individuals that report phantom limb pain are much more likely to report pain in their residual limb,” he says. “Those patients
who deny phantom pain are much less likely to report residual limb pain. That trend suggests that some individuals may have trouble differentiating their pain experiences, or that one pain type triggers the other.” Tonya Rich, PhD, OTR/L, recently studied 50 veterans with limb loss and found that they had difficulty differentiating between residual limb pain
Alleviating Knee Pain and Osteoarthritis Several factors affect the mechanical effects of walking with a prosthesis, including foot shape, foot size, fitness, and step length. “There’s a connection between mechanical aspects [of movement] and the experience of pain,” says Peter Adamczyk, PhD, an assistant professor in the Department of Mechanical Engineering at the University of Wisconsin—Madison. A biomechanist, Adamczyk studies ways to reduce the “collision” that takes place during gait—the impact felt by prosthesis wearers when they land on their feet during each Peter Adamczyk, step of walking. He is particularly PhD concerned with the impact on the knee for prosthetic users and the possibility of osteoarthritis in the intact leg. “Push-off and collision with the ground redirect center-of-mass velocity,” he explains. “Collision is large on the intact limb.” Adamczyk has hypothesized that prosthesis wearers experiencing knee pain could benefit from three separate solutions to reduce the impact of walking with a prosthesis. First, taking shorter steps may reduce collision, he says; while this can burn more energy, it also reduces loading. Second, stiffness and length of the prosthetic foot’s structural keel may correlate to reduced collisions: A stiffer or longer foot “supports body weight further out onto the toe,” he says. Therefore, a prosthesis wearer could potentially soften their landing, reduce the load, and minimize pain by switching to a prosthetic foot that is one or two sizes longer than their natural side foot, he suggests, although he points out this idea has not yet been researched. Third, “to some extent, there’s evidence supporting the notion that powered prostheses” can help reduce the load, thereby reducing the long-term risk of osteoarthritis and pain, says Adamczyk. More research is needed on each of these three suggestions, he emphasizes, to test if they actually do help with the collision phase of walking and potentially reduce pain.
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and phantom pain. In some cases, what they called phantom pain was located where their residual limb met their prosthesis, “so it was actually residual limb pain,” says Rich, an occupational therapist and researcher at the Minneapolis Adaptive Design Engineering (MADE) Program at the Minneapolis VA and an assistant professor in the Department of Rehabilitation Medicine at the University of Minnesota. “We identified that there are education needs as far as how veterans learn to differentiate that pain.”
Tonya Rich, PhD, OTR/L
The biggest takeaway from the survey, according to Rich, “is that phantom limb pain is highly variable.” While some participants experienced very intense phantom pain just a few times a year, others reported experiencing discomfort in the “phantom” area several times a day. “There are very few commonalities between patients,” says Rich. Rich also found that many patients were unaware of strategies that may reduce phantom pain, without the use of medications or over-the-counter drugs. “We found that 54 percent of veterans had one or fewer nonpharmacological techniques they had tried for this type of pain, in our sample,” says Rich. “This means that there are a lot of common ways to manage this pain” that had not been communicated to patients. She encourages prosthetists to ensure their patients are familiar with “very basic nonpharmacological interventions.” For example, “Wearing a shrinker sock is reported to be beneficial,” she says. Activity pacing can ensure patients aren’t overdoing activities at certain times and are instead breaking up tasks and considering the “wear schedule” of their prosthesis.
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Psychosocial Factors Linked to Back Pain At the Delaware Limb Loss Studies Lab, Samantha Stauffer, MSOP, CPO, and her team looked at self-reported outcome measures of individuals with a major lower-limb amputation and long-standing low-back pain. “Individuals who remained unemployed more than a year after their amputation had lower prosthesis use, increased perceived disability, increased anxiety, and poorer coping with their pain, even though there were no differences in pain intensity when compared to those who were employed,” Stauffer says. “What that means is that asking about Samantha Stauffer, pain intensity alone might not provide MSOP, CPO enough information about prognosis. Emerging pain research suggests that addressing psychological factors may be critical.” Several treatments exist for low-back pain, depending on the etiology, according to Stauffer. “Determining underlying causes may require a referral to another member of the patient’s healthcare team, such as a physical therapist, psychologist, or physician specializing in pain management,” she says. “Strengthening and mobility exercises have been shown to be effective at reducing low-back pain in the general population. For patients with chronic pain, pain education and cognitive behavioral therapy … may be needed to improve function and reduce disability. “Biomechanics may contribute to the increased prevalence of low-back pain after amputation, but biomechanics are unlikely to tell the whole story,” adds Stauffer. “Just as we, as practitioners, assess physical presentations of our patients, we should screen for psychosocial factors that may be contributing to their pain.” Prosthetists increase their value to the healthcare team and can positively impact patients’ outcomes when they identify the need for and facilitate timely referrals for factors outside their scope of practice, according to Stauffer. “We should always acknowledge the patient’s pain, as all pain is real even if we can’t identify the source, and refer when our efforts, such as prosthetic adjustments, do not resolve their symptoms,” says Stauffer. “It is also vital to recognize when pain is resulting in significant mental stress, which may manifest as major depression or suicidal ideation, and facilitate immediate referral.”
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Rich also advocates mirror therapy for phantom pain—a technique that was underreported in the veteran survey. “Mirror therapy is where you actually use a mirror alongside your contralateral limb, so you have this mirrored impression as if you have both limbs, and you do a series of exercises as you’re watching in the mirror to give the brain the feedback that the limb is there,” she explains. “One theory is that the body keeps sending all these pain signals because it’s not getting that feedback. For some people with limb loss, mirror therapy can be highly effective.” Rich recently launched a new study—a two-year VA-funded project in partnership with the University of Minnesota, Center for Magnetic Resonance Research—focusing on phantom limb pain and neuromodulation. “We are studying both the maps of the brain (functional MRI or fMRI task) and how the brain circuits are active at rest,” she explains. “Together, this information will give us a window into the brain. If we can identify, potentially, a brain circuit that’s contributing to pain, we may be able to design interventions to either up-regulate that brain circuit or down-regulate that brain circuit. For example, if we find there is a circuit that’s overactive in people who have more pain, we can design interventions to inhibit that brain circuit.” Cole Cheney, MD, a graduating resident at the University of Utah School Hospitals and founder of Cheney and Associates Medical Consulting, also is studying this type of pain. He is part of a team that recently conducted a systematic review of percutaneous nonsurgical interventions for phantom and/or residual limb pain. In addition, he is leading a grant-funded trial evaluating radiofrequency ablation for neuromas: a nonsurgical, minimally invasive procedure that, traditionally, uses heat to reduce or stop the transmission of pain; radiofrequency waves ablate, or “burn,” the nerve that is causing the pain, theoretically eliminating the transmission of pain signals to the brain.
Cheney and his team use MRI to identify the neuroma in the distal residual limb of study participants, before testing whether an anesthetic injection temporarily eases the participant’s pain. If that works, then they proceed to the ablation technique, where they use a probe heated to 60 degrees Celsius near the neuroma for three minutes; this destroys the distal end of the nerve while preserving muscle and skin. “We’ve seen good outcomes” in terms of pain reduction, opioid use reduction, and increased activity among study participants, says Cheney. He intends to close enrollment for this study in the next few months, then analyze and publish the findings.
Cole Cheney, MD
Cheney has plans to test other techniques for reducing pain, including peripheral nerve stimulation and dorsal root ganglion stimulation/ spinal cord stimulation—structures in the spinal cord that plays a key role in the development and management of chronic neuropathic pain. He will be joining Northwestern’s Pain Department as a fellow in July, where he will expand his research to contralateral limb interventions. “One study showed that trigger-point injections on the sound side [among individuals with limb loss] showed improvements in pain on the affected side,” similar to how
mirror therapy can aid patients with phantom limb pain, according to Cheney. “We will look at lidocaine injections and eventually peripheral nerve stimulation” on patients’ intact limbs to see if they help ease limb loss pain on the other side, he says.
Of course, there are some techniques today that prosthetists can try to help alleviate some of the pain their patients may be experiencing. For example, a new, well-fitting socket can relieve residual limb pain and/or sound-limb and low-back pain caused by compensating for a poor socket fit and prosthesis control. In addition, prosthesis alignment is an often-overlooked contributor to pain. “For example, aligning a prosthesis ‘too safe’ makes it more difficult and requires more and asymmetric muscle activation/power to initiate swing, resulting in overuse pain over time,” Kannenberg says. “Aligning a prosthesis ‘too functional’—or, in other words, too unstable—requires asymmetric, untimely, and unphysiological muscle activation/power to stabilize the prosthesis and prevent it from collapsing, which may also result in overuse pain over time,” he says. When it comes to component selection, “prosthetists should aim at reducing or even preventing compensatory mechanisms that usually require asymmetric, untimely, and unphysiological muscle activation/ power, reducing or eliminating the use of additional walking aids, and selecting components that are most appropriate for the activities that their patients do on a regular basis,” adds Kannenberg. For example, patients who negotiate heavily uneven terrain and steeper slopes on a regular basis may benefit from a hydraulic or microprocessor-controlled ankle with sufficient range of motion, rather than a foot with a rigid ankle attachment, according to Kannenberg. “If a patient is a fast walker
who walks distances of three miles or 7,500 steps or more on a typical day, then prosthetists may want to consider a powered foot to help alleviate pain.” Kannenberg points to the study of 57 subjects with unilateral transtibial amputation and K3 mobility. “We found that patients reported significant and clinically meaningful reductions in sound-knee, amputated-side knee, and low-back pain when using a powered prosthetic foot (BiOM or Empower) as compared to their recalled pain when using their previous passive prosthetic feet, even when the recalled pain ratings were adjusted for recall bias,” he says. Significantly more patients reported no sound-knee pain, no low-back pain, and no pain in all three body regions surveyed with use of powered, rather than passive, feet. “Significantly fewer patients reported pain of 3 or greater out of 10 in the sound knee, amputated-side knee, lower back, and all three body regions with the powered as compared to the passive feet,” says Kannenberg. The manuscript of this study is currently under review at the Journal of Rehabilitation and Assistive Technologies Engineering.
Improving Mobility and Quality of Life
As prosthetists do their part to help patients identify their pain and minimize their discomfort, individuals with limb loss will be increasingly likely to use their prostheses and participate in activities. “What I found, anecdotally, is that when people have experienced a lot of phantom limb pain, their inactivity skyrockets, so they’re not putting on their prosthesis; they’re not going out in public,” says Rich. “If we can develop effective techniques around pain management, I would hope to see an increase in activity, an increase in functional use of prostheses, and more participation in daily life.” Christine Umbrell is a contributing writer to O&P Almanac. Reach her at firstname.lastname@example.org. O&P ALMANAC | MAY 2021
Reconnect, Recharge, and Refresh Your Knowledge 2021 SAVE THE 2021 DATES
Join your colleagues in Boston—or virtually—and immerse yourself in the latest O&P education at the 2021 AOPA National Assembly
T’S TIME! After 18 months of limiting social
interactions to prevent further spread of the coronavirus, the nation is opening back up—and AOPA is ready! The 2021 AOPA National Assembly will be held in-person in Boston, September 9-11, and will be followed by virtual presentations one week later, September 16-18, in a hybrid format designed to be accessible to all O&P stakeholders. This year’s Assembly will offer many opportunities to connect with other O&P professionals, catch up on the latest O&P research, and learn easy-to-implement clinical and business strategies. There will be dozens of educational sessions to choose from, but here’s a sneak peek at four sessions you should plan to attend at this year’s premier O&P event.
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#AOPA2021 Prosthetics: Old School Vs. High-Tech You won’t want to miss this debate on prosthetic fabrication, scanning, and socket design, which will address the benefits of both conventional care and the cutting edge in O&P. This dynamic session, called “Human Vs. Machine, Fred Flintstone Vs. George Jetson, Plaster Stains Vs. Carpal Tunnel Syndrome: Who Will Win— The ‘Tried and True’ or the Newest Tech?” will be presented by Jim Young, CP, LP, owner of Amputee Prosthetic Clinic in Georgia, and Jeff Erenstone, CPO, owner of Mountain Orthotic & Prosthetic Services in Lake Placid, New York. “Much like words in our language evolve, so do the processes and materials that we use to create things,” says Young. Both Young and Erenstone use digital technology to some extent in their practices. But while Young says he has “yet to find a digital scanner that will capture what I believe to be the most crucial proximal area when creating a transfemoral prosthetic socket,” Erenstone is an advocate of scanning and 3D-printing technologies. “I depend a lot on my digits to provide me with feedback by palpating boney prominences, determining tissue consistency, and identifying pressure-sensitive areas,” explains Young. He wears a transfemoral socket and has experienced first-hand “the difference between ‘close’ and ‘correct.’” Erenstone, on the other hand, describes 3D printing as an exciting new technology that will have “a huge part to play in the future of fabrication in O&P.” But both presenters see value in both traditional and newer O&P processes and procedures, and they plan to offer “a light-hearted discussion” about the pros and cons of each. “For example,” explains Young, “if I am using plaster, then heat and humidity may influence set time. Conversely, Jeff may be having computer software complications, [unreliable] internet
service, or a computer crash,” he says. “So, old school verses new school … each will have fans and detractors.” The presenters will come to the session dressed in costume to debate “in character,” Erenstone adds: “The ‘futurist’ will have a scripted debate with the ‘old-timey craftsman.’ We want to make it fun while imparting knowledge in a self-deprecating way.” “Information is critical for making informed decisions. It is important to talk about the pros and cons of different approaches and be familiar with as many styles and alternatives to do our jobs as possible,” says Young. “Although the tools, materials, and processes may change, the most important aspect—the goal of optimizing patient outcomes—does not.”
Orthotics: The Latest in Ankle Bracing
Stay on the cutting edge of orthotics by attending this symposium on updates in ankle-foot orthosis (AFO) technology. Andreas Kannenberg, MD (GER), PhD, executive medical director for Ottobock Healthcare LP, and Gerald Stark, PhD, MSEM, CPO, LPO, senior clinical specialist at Ottobock, will lead the session “Advances in AFO Technology,” which will focus on the recently introduced “next-generation” orthotic ankle designs that promise to provide more dynamic movement and rollover. “Orthotists commonly employ componentry that either locks, blocks,
or resists movement,” explains Stark. While providing a great deal of safety, these types of devices sacrifice possible dynamic movement during gait, he says. “New componentry of the ankle and knee promises to provide dynamic assist as well as modular adjustment that can provide increased movement during gait.” This new componentry requires a change in clinical approach to enhance and increase freedom of movement, according to Stark. Speakers will examine the integration of these designs within orthotic clinical practice. Speakers from research and manufacturing will present and discuss the concepts of evaluation, selection, adjustment, and subsequent outcomes during this cross-platform roundtable discussion. “The areas that will be addressed are the collective similarities and differences of dynamic orthotic ankle designs as well as perspectives in how they are implemented,” Stark says. Presenters will share relevant research on patient selection and the efficacy of this componentry. “Clinical optimization strategies will also be shown, demonstrating how the devices are tuned and applied with other orthotic devices,” Stark notes. Session leaders will ask questions and “gather contributions from attendees as to the effectiveness of these alternative components,” he adds. Clinicians interested in the benefits of more dynamic movement for orthotic wearers should mark their calendars for this session. O&P ALMANAC | MAY 2021
Pedorthics: Diabetic Foot-Care Strategies
Whether you’re an orthotist or a pedorthist, this symposium—“Management of the Diabetic Foot”—will cover many aspects of foot care and boost your clinical knowledge. “Diabetes numbers just keep increasing—not only in the aging population, but in all age groups,” says Dennis Janisse, CPed, founder of National Pedorthic Services Inc. Approximately 30.3 million U.S. residents have diabetes—23.1 million diagnosed and 7.2 million undiagnosed, according to the Centers for Disease Control and Prevention; that equates to 9.4 percent of the U.S. population. It’s also estimated that 84.1 million U.S. adults have prediabetes. Given these statistics, “orthotic, prosthetic, and pedorthic practitioners will be seeing more diabetes patients with varying degrees of issues,” says Janisse. Janisse will be leading this symposium in Boston, accompanied by Erick Janisse, CO, corporate trainer at DJO Global, and Brian Lane, CPed, director of education for Dr. Comfort. They will share their expertise on a wide range of topics of critical importance to clinicians who treat patients with diabetes. Participants will learn about the prevalence of the disease and how to manage some of its most complicated 30
MAY 2021 | O&P ALMANAC
conditions and deformities. “Owners, practitioners, administrators, billing personnel—everyone on the patientcare team needs this information to care for their diabetes patients appropriately, effectively, and efficiently,” says Janisse. The presenters will drill down to discuss several topics in detail, including the impact of diabetes on the foot; diabetes and obesity in the United States; pedorthic management of the partial foot; the Charcot foot; and the “total package” surrounding the diabetic shoe. In addition, attendees will learn how to navigate the Therapeutic Shoe for Persons With Diabetes (TSPD) benefit, and “how to make the TSPD benefit work,” Janisse says. Participants will return to their offices with tangible solutions to assist them in treating their diabetic patients.
Best Business Practices: Documentation Tips for Advanced Devices
Learn tips for ensuring your patients have access to the most appropriate devices in “Justifying Medical Necessity and Documentation.” Participants in this symposium will hear how medical necessity for advanced prosthetic and orthotic devices should be documented in the physician’s and CPO’s records, says Kannenberg. He will lead this session alongside Harry Schwartz, MD, from MossRehab Einstein in Philadelphia, Danielle Melton, MD, from Memorial Hermann Houston, and Linda Collins, MS, from Össur. The language in the policies stresses that the patient must meet certain criteria to be eligible for advanced technology. “However, from a physician’s perspective, it’s all about identifying safety and/or mobility needs of the patient that are unmet by the current prosthesis/orthosis,” explains Kannenberg. “If a patient meets the policy criteria but doesn’t have least one unmet need, then he or she is basically eligible for advanced technology but doesn’t demonstrate the medical necessity—need—for it.”
Documentation should demonstrate the medical necessity for an advanced device, according to Kannenberg. “For instance, if a patient does all the activities listed in microprocessorcontrolled knee (MPK) policies with a non-microprocessor-controlled knee without any problems, what would be the justification to fit an MPK that is [much more] expensive? Take-home message: A patient who is doing great doesn’t qualify for an upgrade.” Creating the record is “like walking a fine line,” Kannenberg adds: “You have to make sure that the patient meets all the criteria in the policy to demonstrate eligibility for advanced technology but still needs to demonstrate at least one unmet safety and/ or mobility need,” he explains. “So, the patient must be doing good enough with the current prosthesis or orthosis to meet the policy eligibility criteria, but not as good as he or she wants or needs to be.” Kannenberg and his co-presenters will discuss appropriate documentation in detail—to ensure coverage of the most appropriate technology for O&P patients.
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NSC Need-To-Know Tips for smoother enrollment processes during the pandemic and beyond
Editor’s Note: Readers of Compliance Corner are now eligible to earn two CE credits. After reading this column, simply scan the QR code or use the link on page 33 to take the Compliance Corner quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.
E! QU IZ M EARN
HE NATIONAL SUPPLIER CLEARINGHOUSE (NSC) is the single organi-
zational entity responsible for issuing or revoking Medicare supplier billing privileges for suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). The COVID-19 public health emergency (PHE) continues to affect many aspects of enrollment. By sharing information, NSC hopes to make the enrollment process easier for everyone.
Due to the current pandemic PHE, the following waivers are in place regarding Medicare suppliers who are currently, or are in the process of enrolling as, DMEPOS suppliers: • Supplier Standard 9: Business phone, maintains a primary business telephone that is operating at the appropriate site listed under the name of the business locally or toll-free for beneficiaries. • Supplier Standard 30: Minimum hours of operation, except as specified in paragraph (c)(30)(ii) of this section, is open to the public a minimum of 30 hours per week.
In addition, NSC is resuming normal site visit activity; therefore, any enrollment application received will not be finalized until a site visit is conducted. Revalidations also have been suspended. Visit the CMS website and view the “Current Emergencies” page for more information.
Medicare Enrollment Application Fee
On Nov. 23, 2020, CMS issued a notice regarding the “Provider Enrollment Application Fee Amount for Calendar Year (CY) 2021.” Effective January 1, the CY 2021 application fee is $599 for institutional providers that are: 1. Initially enrolling in the Medicare or Medicaid program or the Children’s Health Insurance Program (CHIP). 2. Revalidating their Medicare, Medicaid, or CHIP enrollment. 3. Adding a new Medicare practice location. This fee is required with any enrollment application submitted from Jan. 1 through Dec. 31, 2021. (Note: As of Feb. 1, 2021, due to the COVID-19 PHE, enrollment fees will continue to be waived.)
MAY 2021 | O&P ALMANAC
Bonds are required to obtain or maintain Medicare billing privileges, per a CMS directive on Dec. 29, 2008. A DMEPOS surety bond is a bond issued by an entity (the surety) guaranteeing that a DMEPOS supplier will fulfill an obligation or series of obligations to a third party (the Medicare program). If the obligation is not met, the third party will recover its losses via the bond. Surety bonds are required whether the DMEPOS supplier is nonparticipating or participating. With that being said, there are certain suppliers that may qualify for exemption. The exemption requirement can be found in its entirety in 42 CFR 424.57(d)(15). Here are some applicable exemptions for suppliers that deal with orthotic and prosthetic services: “State-licensed orthotic and prosthetic personnel in private practice making custom-made orthotics and prosthetics are exempted from the surety bond requirement if: (1) the business is solely owned and operated by the orthotic and prosthetic personnel, and (2) the business is only billing for orthotics, prosthetics, and supplies.”
www.palmettogba.com/licensure/licdirec. nsf/NSCLicensureMap_N, to assist suppliers with changes and updates; however, this directory is meant only as a guide. It is the responsibility of the supplier to ensure compliance with state licensure requirements. Additionally, suppliers may utilize the NSC Web Form Submission option to submit licenses.
NSC offers the NSC Web Form Submission option at www4.palmettogba.com/NSC_WebForm_Submission/. This tool allows suppliers to respond to requests from NSC by uploading required documents. Items that can be uploaded include appeals, certificates of insurance, licenses, National Provider Identifier letters, responses to Supplier Audit and Compliance Unit requests, and surety bonds; in addition, suppliers will be able to respond to the Competitive Bidding Implementation
Contractor (CBIC) preliminary bid evaluation directly from the web form tool. Accessing the online NSC Web Form Submission tool reduces mailing time and alleviates the paper burden associated with submitting required documents. This tool does not allow for CMS-855S applications or any changes to information, and you may only submit documentation if you have a DMEPOS Provider Transaction Access Number (active or revoked). Browse the NSC website at www. palmettogba.com/palmetto/nsc.nsf for additional information, and sign up for listservs at www.palmettogba.com/ home.nsf/emaillobselect to get the most up-to-date information delivered straight to your inbox. Finally, if you have additional questions regarding enrollment, you can email NSC directly at email@example.com. EDITOR’S NOTE: All of the information provided in this article was current as of April 2021. Malisa Rogan is the senior provider relations representative at National Supplier Clearinghouse. Take advantage of the opportunity to earn two CE credits today! Take the quiz by scanning the QR code or visit bit.ly/OPalmanacQuiz. Earn CE credits accepted by certifying boards: www.bocusa.org
Supplier Standard 1 mandates that “if a state requires licensure to furnish certain items or services, a DMEPOS supplier must be licensed to provide the item or service.” NSC provides a Licensure Directory, available at
O&P ALMANAC | MAY 2021
Giving Voice to the Underrepresented UW researcher focuses studies on improving care for marginalized populations
O&P Almanac introduces individuals who have undertaken O&P-focused research projects. Here, you will get to know colleagues and healthcare professionals who have carried out studies and gathered quantitative and/ or qualitative data related to orthotics and prosthetics, and find out what it takes to become an O&P researcher.
OR CODY L. MCDONALD, PhD,
MPH, CPO, patient interactions during the early days of her career spurred her decision to pursue O&P research goals. “First as a clinician and then as an orthotist mentor working in Laos, I attempted to collect data to assess my patients’ outcomes and inform treatment plans,” recalls McDonald. “Unfortunately, I did not have the
MAY 2021 | O&P ALMANAC
PHOTO: Cody L. McDonald, PhD, MPH, CPO
Cody L. McDonald, PhD, MPH, CPO, works with a patient.
training in outcome measurement that our master of prosthetics and orthotics (MPO) students now receive, so I struggled to meaningfully implement evidence-based practice on my own.” McDonald, who earned a bachelor’s degree in prosthetics and orthotics from the University of Washington (UW) in 2006, spent her early career as a clinician in the Department of Orthopedic Surgery at the University of California, San Francisco. In 2012, she pivoted to spend a year in Vientiane, Laos, as part of the Cooperative Orthotic and Prosthetic Enterprise (COPE), which works in collaboration with the Laos Ministry of Health Rehabilitation Centers to provide prostheses, orthoses, and therapy. “My position was funded under a USAID grant,” she explains. McDonald worked with a team of mentors, including a physical therapist (PT), occupational therapist, and pediatric PT, who provided training for local orthotists, prosthetists, and therapists. She helped develop care pathways for patients and engaged in outreach to increase awareness about COPE and available rehabilitation services. The year spent overseas served as a “huge learning experience” for McDonald. “My time working in Laos solidified my interest in O&P education and global
McDonald, far left, participates in a focus group. O&P development. That experience motivated me to return to school for a doctorate to obtain the skills necessary to conduct clinical research and teach.” She subsequently earned a master’s degree in public health in 2017, and a doctoral degree in rehabilitation science in 2019—both from UW.
PHOTOS: Cody L. McDonald, PhD, MPH, CPO
McDonald, who today serves as acting assistant professor in UW’s Department of Rehabilitation Medicine, is most interested in research that helps improve care for marginalized populations, both in the United States and abroad. “This can come in many shapes and forms,” she says. “Qualitative methods are an important tool for me to truly conduct patientcentered research. I don’t focus on specific etiologies or devices, but rather seek to give a voice to O&P patients who are underrepresented in research and education.” McDonald recently conducted a pilot study to examine how social network analysis methodology can be applied to explore information sharing among faculty in O&P. The research team examined networks of faculty members at a program in the United States and one in Ghana. “We found that the
networks of information sharing were very different, and that social network analysis can provide useful insights into O&P education programs,” she says. For example, in Ghana, the faculty share information frequently with all colleagues, likely due to the singular focus of the program on training O&P students and the lack of other information sources, such as textbooks, other O&P colleagues, manufacturers, and peer-reviewed journals. “In the United States, faculty were much more siloed and were less connected,” she explains. “This is likely due to academic culture and the location of this O&P program within a much larger institution.” She also conducted a systematic review of O&P education research, concluding that education research in O&P is very limited but has been increasing in recent years. The review included studies spanning geographic locations, topics, and methodologies. “Quality of the research varied substantially, and collaborations … should be encouraged to improve the quality of research being conducted in O&P education,” she says. Studies examined teaching/learning methods, aspects of content/curriculum, and program-level topics. “Overall, O&P education research lags behind clinical research
and impedes the ability of educators to employ evidence-based education. We need a culture shift in O&P education to support and encourage research and peer-reviewed publication to better inform education for future clinicians.” In another recent investigation, McDonald studied the global prevalence of traumatic limb amputation. In addition to identifying the geographical areas with highest prevalence of traumatic amputations—East Asia, South Asia, and Western Europe—McDonald determined the leading causes of trauma-related amputation: falls, road injuries, and other transportation injuries. She also identified a need for 75,850 prosthetists to treat the 57.7 million people who have traumatic amputations across the globe. Currently, McDonald is studying “how we prioritize outcomes for lower-limb prosthesis users, and how stakeholders—including payors—define successful outcomes,” she says. “I hope this work will provide insight into how stakeholders differ in their definitions of success and potentially identify areas where we can better align our expectations and goals. Payors are an important group for this conversation, and I’m optimistic that this research will shed light on discord among stakeholders within lower-limb prosthetics.” O&P ALMANAC | MAY 2021
Influencing O&P Students
The mother of two young girls, McDonald hopes that, in the future, she can help spur research in both O&P education and global O&P. “These are two areas in the field that have largely been overlooked,” she says. 36
MAY 2021 | O&P ALMANAC
McDonald speaks at the USISPO Pacific Rim Conference in January 2020. O&P education research “has not yet been prioritized, and funding can be challenging to find,” she says. “As an educator, I need more O&P-specific literature to guide my evidence-based teaching. As a collaborator in global O&P, I need more peer-reviewed evidence and resources to share with international
Notable Works Cody L. McDonald, PhD, MPH, CPO, recently began publishing some of her research and qualitative studies, including the following: • McDonald, C.L., Westcott McCoy, S., Weaver, M.R., Haagsma, J., Kartin, D. “Global Prevalence of Traumatic Nonfatal Limb Amputation.” Prosthet Orthot Int, 2020 Dec 4: 309364620972258. Epub ahead of print. PMID: 33274665. • McDonald, C.L., Kartin, D., Morgan, S.J. “A Systematic Review of Prosthetic and Orthotic Education Research.” Prosthet Orthot Int, 2020 Jun; 44(3): 116-132. PMID: 32301371. • McDonald, C.L., Cheever, S.M., Morgan, S.J., Hafner, B.J. “Prosthetic Limb User Experiences With Crossover Feet: A Pilot Focus Group Study to Explore Outcomes That Matter.” Journal of Prosthetics and Orthotics, 2018; 00(00):12. • McDonald, C.L., Bennett, C.L., Rosner, D.K., Steele, K.M. “Perceptions of Ability Among Adults With Upper-Limb Absence: Impacts of Learning, Identity, and Community.” Disabil Rehabil, 2020 Nov, 42(23): 3306-3315. PMID: 30999780.
PHOTO: Cody L. McDonald, PhD, MPH, CPO
In addition to her research endeavors, McDonald spends much of her time inspiring O&P students to consider research work. She teaches the evidence-based practice course series for UW’s MPO program, which features an introduction to research, critical appraisal of the literature, and two evidence-based practice courses. She also mentors MPO students through their capstone projects in the second year of the program. “I love all the ways that my students challenge me. My students inspire me to think in new ways and question my own assumptions and beliefs,” she says. “I also love to see students grow and change throughout the program and into their careers. I constantly find pride and joy in my students’ successes.” McDonald also teaches introduction to global rehabilitation in the rehabilitation science doctoral program at UW. “This course brings together experts in global health and global rehabilitation to provide an overview of the design and implementation of global rehabilitation projects and programs,” she says. As an executive board member of the U.S. Member Society of the International Society for Prosthetics and Orthotics (USISPO), McDonald is working with Alex Hetherington, CP, to convene a USISPO committee of researchers and clinicians who conduct global O&P research. “We hope to build collaborations among people working in O&P in low- and middle-income countries to support and strengthen the systematic collection of patient and systems-level outcomes,” she says. “We need more people publishing their work in global O&P so prosthetists and orthotists in low- and middle-income countries have resources and examples to draw from and build upon.”
colleagues working in O&P education and developing new O&P programs.” McDonald also hopes to explore important social concepts within O&P education and clinical practice. “While I believe our profession is opening conversations around systemic racism, gender identity, implicit bias, and positionality, we are lacking an evidence base to draw from,” she says. “We need research conducted in this area to inform how we shift our clinical practice and education to better meet the needs of the marginalized groups we serve. “I also think there is an urgent need to examine health disparities in O&P,” McDonald adds. “The current social context of civil unrest and the Black Lives Matter movement have drawn attention to the systemic racism that permeates our society and institutions, including healthcare. We in O&P need to address these issues at all levels—education, clinical practice, personal biases, etc.—and this requires research to show us the current state of the O&P profession and health disparities in O&P clinical care.”
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By DEBORAH CONN
Creating Comfortable Sockets Chicago company distributes system that recreates loading forces on the residual limb
YPRESS ADAPTIVE’S flagship
MAY 2021 | O&P ALMANAC
Owners Laszlo Dallos, Lynn Snyder, PT, and Matt Doering
COMPANY: Cypress Adaptive OWNERS: Matt Doering, Lynn Snyder, PT, and Laszlo Dallos LOCATION: Chicago HISTORY: Six years
The new Symphonie Aqua Compact System
Some of the company’s recent developments include the introduction of a new transfemoral version of the Aqua System as well as a more portable unit for transtibial and through-knee amputations. The portable system is useful for facilities that want to share the system across several offices or satellites, because it doesn’t require a hookup to air and water sources. The standard system, which is designed to be fixed in place, is more modular, allowing users to add features as needed. Several small research studies have focused on the Aqua System, and a three-year, multisite study by the U.S. Department of Defense is about midway through completion. A committee of practitioners and Cypress Adaptive representatives is investigating whether the system merits a specific L code for reimbursement. In addition to the Aqua System, Cypress Adaptive works with independent inventors to develop other prosthetic products, including expulsion valves, suspension
sleeves, elevated vacuum systems, and prosthetic knees. The founder of Romedis, Andreas Radspieler, developed a new suspension sleeve that, unlike traditional sleeves, eliminates pressure across the patella and behind the knee. “It is a completely different concept, and you have to see it to understand it,” Doering says. “Radspieler, who has been the German equivalent of a CPO for 25 years, is the Elon Musk of prosthetics.” Doering expects the new sleeve to be available soon. Like most companies, Cypress Adaptive faced an uncertain future during the pandemic, with a precipitous drop in sales during the first two quarters of 2020. “Fortunately, we were already a pretty lean company, so we just had to watch expenses and readjust our marketing dollars,” recalls Doering. The company began to recover in the third quarter and continues to rebound. As travel halted last year, the company added instructional videos to its website and plans to expand virtual training even when on-site visits are possible again. Doering says the company will continue to refine its products and seek innovations over the next several years. “Our goal is to create tools that make it easier for the practitioner and the user,” he says. “We feel fortunate to be part of this industry. It’s incredibly rewarding, even with changes in the past few years. We love the fact that we are a part of it.” Deborah Conn is a contributing writer to O&P Almanac. Reach her at firstname.lastname@example.org.
PHOTOS: Cypress Adaptive
product is the Symphonie Aqua System, a method of casting amputees developed by the German firm Romedis GMBH. As the company’s exclusive North American partner, Cypress Adaptive markets and distributes the system, which recreates loading forces on the residual limb that match those under actual full weight-bearing conditions. “Historically, prosthetists take an impression while the patient is in a seated position, which can’t mimic the anatomical needs or wants under full load,” explains Matt Doering, co-owner and head of sales, marketing, and education. “Most socket issues occur in a weightbearing position, so doing the hydrostatic full-weight capture allows the prosthetist to create more comfortable sockets, and that leads to great compliance.” Another benefit, he notes, is the consistency the Aqua System brings to regional or national providers. “Even a skilled clinician who casts a patient multiple times won’t get identical results,” says Doering. “This system enables every office to create the same outcome, regardless of its location or the prosthetist’s experience.” In addition to Doering, Adaptive is co-owned by Lynn Snyder, PT, who handles dayto-day operations and customer service, and Lazlo Dallos, head of product development. Snyder works from her home base in New Jersey, while Dallos is based in Boston. The company manufactures expulsion valves in Chicago, where Doering operates.
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MAY 2021 | O&P ALMANAC
Justin Hanes, CPO, LPO, co-clinic lead, digitally scans a patient. Fourroux Prosthetics was established in 1955 in Huntsville, Alabama. Over the past 66 FACILITY: years, the practice has added facilities in Atlanta; Birmingham, Fourroux Alabama; Memphis and Nashville, Prosthetics Tennessee; St. Louis; and Tampa and Pensacola, Florida. Each OWNER: Keith Watson, CPO facility is a standalone, with its own fabrication capabilities where nearly all devices are built. LOCATION: “We have a talented fabricaHeadquartered tion team,” says Ratliff. She cites in Huntsville, an example from two years ago, Alabama, with when the Atlanta facility “built locations in a hybrid body-powered and myoelectric upper-extremity five states prosthesis that was simpler and lighter for the patient than a HISTORY: completely myoelectric device.” 66 years The company has made several adjustments during the pandemic, such as limiting transportation services to one patient at a time and isolating patients at the office, as well as acquiring new cleaning equipment for vans and offices. “A lot of facilities had to lay off staff or close offices, but Fourroux never had to do any of that,” says Eli Walls, a board-eligible prosthetist,
Deborah Conn is a contributing writer to O&P Almanac. Reach her at firstname.lastname@example.org.
PHOTOS: Fourroux Prosthetics
goes the extra mile for its patients—often literally, according to Jenn Arnold, LPN, the company’s executive patientcare coordinator. Each of Fourroux’s Jenn Arnold, LPN eight clinics has an ADA-compliant van to offer no-cost transportation to patients within a 150-mile radius who need assistance getting to and from their Fourroux appointments. “With the services we provide, it’s super important that [patients] come into the office,” Arnold explains. “We do see patients in their homes and in rehab centers, but treating them in the office, where the lab is located, is essential.” Because most patients need to be seen every three months for follow-ups, “we want to make it as easy as possible.” Fourroux also offers same-day fabrication, says Caitlin Ratliff, CP, LP, co-clinic lead. Caitlin Ratliff, “For lower-extremity CP, LP amputees, we can often go from a test fitting at 9 a.m. to a laminated, delivered socket by 5 p.m. For a lot of patients, that can be crucial— particularly those in rural areas.” Ratliff says this service is beneficial to her as a clinician “because I am not hurried in my assessment,” she explains. “I see how the socket looks at 9 [a.m.] and how the volume of the residual limb fluctuates throughout the day. The patient also has many hours to walk and test the fit, giving us good feedback.”
who served his NCOPE residency at Fourroux. “In fact, we opened three new facilEli Walls ities last year.” Fourroux has temporarily put its amputee support groups, which normally meet quarterly, on hiatus, but hopes to reconvene with appropriate guidelines, says Ratliff. Other community-based activities include offering educational sessions to students at local colleges, universities, and technical schools to raise awareness of prosthetics as a career. Both Arnold and Ratliff participated as event staff at the U.S. Paralympic Cycling Open in Huntsville in April. The facility leverages advanced technology, such as computer-aided design and manufacturing, although technicians also use hand casting when appropriate, depending on the level of amputation and the patient’s needs. “We are also primed and ready to convert to 3D printing when it becomes more available and accessible,” says Ratliff. “We can already save files to that format. It’s an exciting time to be a clinician with technology advancing as it is.” Fourroux had to forgo a big bash for its 65th anniversary in 2020, but it may have even more to celebrate the next time a milestone comes along. “We’re not interested in growth for growth’s sake,” says Walls, “but we will do so if the right people come along.” The right people, according to the company philosophy, exhibit four attributes: honesty, integrity, an innate ability to care for people, and self-motivation. As a result, Arnold notes, staff turnover is rare; everyone unites in putting patients first.
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Documentation: Working With Your Referral Source
Documentation is key to reimbursement, and missing documentation from your referral sources is often the primary reason for denial. Learn some tips and strategies to ensure you are getting the documentation you require from your referral sources—in a timely manner.
provide the most reliable business information and CE credits for your staff at a single office location. Visit www.AOPAnet.org/education/monthly-webinars for details and registration information.
Prior Authorizations: What We Have Learned, and What You Need To Know
Why are prior authorization requests being denied? Learn the steps you can take to avoid common errors. Access the latest details released by CMS and the durable medical equipment Medicare administrative contractors about the prior authorization process.
Don’t Sleep on the Latest AOPA Member Resource
RE YOU UTILIZING YOUR AOPA MEMBERSHIP?
Attend the upcoming live tutorial to learn about one of the best resources available for O&P practices, the AOPA Co-OP. A Wikipedia for all things O&P, the Co-OP is a one-stop resource for information about reimbursement, coding, and policy. This searchable database provides up-to-date information on developments in Medicare policy, statespecific legislation, private-payor updates, and more. Members can access detailed information on everything from modifiers to product-specific L codes and associated policies. Register for the next Co-OP Live Tutorial hosted by AOPA
MAY 2021 | O&P ALMANAC
Tutorial Webinars Co-OP Live on Friday at Noon ET • June 4
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Director of Strategic Initiatives Ashlie White, who will demonstrate how to use the Co-OP and answer all of your questions. Any employee of an AOPA member firm is welcome to join this free tutorial. Learn more at www.AOPAnet.org/resources/co-op.
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ALPS Flex Sleeve (SFX) ALPS Flex Sleeve (SFX) is a prosthetic suspension sleeve made with a seamless knitted construction in high-density gel to provide maximum comfort. The SFX has a 30-degree preflexion, which allows for ease of bending and reduces bunching behind the knee. The SFX contains HD gel that provides active amputees with a great degree of control. Our SFX is available in one length that accommodates most users with 3-mm uniform thickness. We offer this sleeve product in the options of either a beige or grey color. Call us or visit www.easyliner.com for more information.
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MAY 2021 | O&P ALMANAC
Coyote Composite is a natural fiber made of Basalt Braid (lava rock). A nontoxic and noncarcinogenic alternative to carbon fiber. For more information, contact Coyote at 208/429-0026 or visit www.coyote.us.
The Original Preflexed Suspension Sleeve ESP created the Flexi family of suspension sleeves as a comfortable, durable, and cost-effective alternative to traditional suspension sleeves. Preflexed at 43 degrees for maximum comfort and natural unrestricted movement. For more information, call ESP LLC at 888/932-7377 or visit www.wearesp.com.
PDQ BT-4 Infrared Oven The BT-4 Infrared Oven is capable of bubble forming and heating sheet plastic while taking up a minimal amount of floor space. The BT-4 is big enough to heat most KAFO sheet plastics and has enough drop for even the biggest check socket. The BT-4 has the same speed and reliability you’ve come to expect from PDQ® Infrared Ovens. The eight, 1000-watt emitters, four on top and four on bottom, along with the dual electric fans, allow bubble-forming plastics to be heated evenly and efficiently. The BT-4 is truly the best of both worlds with its small size and large capacity. Visit www.fillauer.com for more information.
MARKETPLACE LEAP Balance Brace Hersco’s Lower-Extremity Ankle Protection (LEAP) brace is designed to aid stability and proprioception for patients at risk for trips and falls. The LEAP is a short, semirigid anklefoot orthosis that is functionally balanced to support the foot and ankle complex. It is fully lined with a lightweight and cushioning Velcloth interface, and is easily secured and removed with two Velcro straps and a padded tongue. For more information, call 800/301-8275 or visit www.hersco.com.
Naked Prosthetics Naked Prosthetics designs and manufactures high-quality prosthetic devices specifically for finger loss. Our mission is to assist people with digit amputation(s) and positively impact their lives with fully articulating, custom finger prostheses. Our product aims to restore the ability to perform most tasks, supporting job retention and an active lifestyle. Our customers have lost fingers to power tools, equipment malfunctions, injury in the line of military service, random accidents, and infections; in some cases, multiple digits have been lost. NP provides a viable functional prosthesis, as opposed to a passive cosmetic solution. Our design mimics finger motion and utilizes the remainder of an amputee’s digit to power the device. For more information, visit www.npdevices.com.
Ottobock Professional and Clinical Services: Here for You Ottobock Professional and Clinical Services is the largest and most experienced team of clinical specialists in the industry. We’re here to provide the best possible information, accessibility, and support for you and your customers. It is our mission to improve the quality of life of those with mobility needs by empowering people through clinical education, training, and technical support with skill and compassion. Visit our website for online education and enjoy our Experts on Demand webinar series for the latest in prosthetic and orthotic clinical information. Visit professionals.ottobockus.com/Education to learn more.
We’re Here To Help As a healthcare provider, your top priority is getting your patients the medical devices they need. At Ottobock, we aim to provide you with the tools and education to help make that happen. We know that the reimbursement process isn’t always easy—let us help you navigate the complexities and challenges that come with it. From online training to consulting services, we have the resources you need to help your patients achieve quality for life. Visit https://shop.ottobock.us/Reimbursement to learn more.
O&P ALMANAC | MAY 2021
MARKETPLACE RUSH ROGUE® The PDAC-approved RUSH ROGUE® provides the most realistic and dynamic foot and ankle motion available. The Vertical Loading Pylon (VLP) provides vertical shock relief while offering +/- 8 degrees of torsion, allowing the user to push the foot and themselves to the limits. The RUSH ROGUE is made of our advanced fiberglass composite, which is three times more flexible than conventional prosthetic feet. The roll-through characteristics of the foot provide exceptional energy return with no “dead spot.” The RUSH ROGUE is also available in the EVAQ8 elevated vacuum and H2O models. #goROGUE
The Xtern Foot Drop AFO by Turbomed Orthotics Think outside the shoe! This one-of-akind orthosis (AFO) is a game changer for foot drop patients: The Xtern is totally affixed outside the shoe to maximize comfort, and prevent skin breakdown and rubbing injuries. Its flexibility promotes maximal ankle range of motion and calf muscle strength. The Xtern allows running, walking, and even mountain hiking as long and as far as you want without any restrictions, and moves from sandals to boots flawlessly. Turbomed’s innovative products are designed in Quebec, Canada, sold in over 26 countries, and distributed by Cascade in the United States. Visit turbomedusa.com to get your life back!
Welcome to AOPA Connection, the one-stop-shop for all things AOPA. Logging into AOPA Connection you will instantly have access to all your AOPA benefits, including: • AOPAversity • Your Membership Record • Your Individual Profile • Event Calendar • Bookstore • Co-OP But, it doesn’t stop there! We are pleased to introduce a new benefit accessible through AOPA Connection, My O&P Community. In this online community of your O&P colleagues you can get guidance, share advice, have one-on-one and group conversations, and access resources.
FOLLOW US @AmericanOandP
MAY 2021 | O&P ALMANAC
CL MB The path to the top isn’t always easy. But at Hanger, no one has to do it alone. And there’s no limit to how high any of our team members can climb. Hanger is the clinical leader in orthotic and prosthetic care because we hire the best and the brightest. We provide vast resources, opportunities for career advancement, and the most innovative technology in our field to help them do what they do best: care for our patients. We’re passionate about the life-changing, fulfilling work we do to empower our patients to take on life’s challenges with increased mobility, independence and self-confidence. We know this important work starts by supporting our employees. Empower your career. Apply today and climb higher at Hanger.
Hanger, Inc. is committed to providing equal employment to all qualified individuals. All conditions of employment are administered without discrimination due to race, color, religion, national origin, sex, age, disability, veteran status, citizenship, or any other basis prohibited by federal, state, or local law.
Opportunities for O&P Professionals
WANTED! A few good businesses for sale.
Job Location Key: - Northeast
Lloyds Capital Inc. has sold over 150 practices in the last 26 years.
- Mid-Atlantic - Southeast - North Central
If you want to sell your business or just need to know its worth, please contact me in confidence.
- Inter-Mountain - Pacific
Hire employees and promote services by placing your classified ad in the O&P Almanac. Include your company logo with your listing free of charge.
Barry Smith Telephone: (O) 323/722-4880 • (C) 213/379-2397 Email: email@example.com
Refer to www.AOPAnet.org for content deadlines. Ads can be posted and updated any time online on the O&P Job Board at jobs.AOPAnet.org. No orders or cancellations are taken by phone. Send classified ad and payment to: O&P Almanac, Calendar, P.O. Box 34711, Alexandria, VA 22334-0711 or email jburwell@AOPAnet.org along with VISA or MasterCard number, cardholder name, 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. O&P Almanac Careers Rates Color Ad Special 1/4 Page ad 1/2 Page ad
Member $482 $634
Nonmember $678 $830
Listing Word Count 50 or less 51-75 76-120 121+
Member $140 $190 $260 $2.25 per word
Nonmember $280 $380 $520 $5 per word
ONLINE: O&P Job Board Rates Visit the only online job board in the industry at jobs.AOPAnet.org. Job Board 50 or less
A large number of O&P Almanac readers view the digital issue— If you’re missing out, visit issuu.com/americanoandp to view your trusted source of everything O&P.
Connecting highly qualified O&P talent with career opportunities EMPLOYEE
• Research who is hiring • Apply online for job openings • Free résumé review.
For more opportunities, visit: http://jobs.AOPAnet.org. SUBSCRIBE
AOPA’s O&P Career Center
• Post your job in front of the most qualified group of O&P professionals • Search anonymous résumé database to find qualified candidates • Manage your posted jobs and applicant activity easily on this user-friendly site.
LOG ON TODAY! https://jobs.AOPAnet.org 48
MAY 2021 | O&P ALMANAC
Career Opportunities... California
CO-Modesto CPO-Salinas Oregon CPO –Portland
Established in 1987, Pacific Medical Prosthetics and Orthotics has become a tenured company in the industry for superior patient care, products and services.
The positions we offer are created for candidates that are looking to create opportunity, self-driven, motivated, and enjoy serving and helping others.
To apply, submit resume to: firstname.lastname@example.org
A competitive salary, benefits and profit sharing are offered based on position/experience.
Our Culture & Commitment “We will serve and help others grow personally, professionally, and strive to put others needs first and foremost as demonstrated by our positive attitude, teamwork and professionalism.” AD INDEX
Advertisers Index Company Allard USA
ALPS South LLC
Coyote Prosthetics & Orthotics
Cailor Fleming Insurance
1 800/301-8275 888/977-6693
O&P ALMANAC | MAY 2021
PrimeFare East. Nashville Renaissance Hotel and Conference Center. In-Person Meeting. For more information, contact Cathie Pruitt at 901/359-3936 or email email@example.com, or Jane Edwards at 888/388-5243 or email firstname.lastname@example.org. Visit www.primecareop.com.
ABC: Application Deadline for Fall CPM Exams. All practitioner candidates have an additional 30 days after the application deadline to complete their residency. Contact 703/836-7114, email certification@ABCop.org, or visit ABCop.org/ individual-certification.
2021 June 1
ABC: Application Deadline for August Written & Simulation Exams. Applications must be received by June 1 for individuals seeking to take the August Written and Simulation certification exams. Contact 703/836-7114, email certification@ABCop.org, or visit ABCop.org/individual-certification.
ABC: Practitioner Residency Completion Deadline for August Written & Simulation Exams. All practitioner candidates have an additional 30 days after the application deadline to complete their residency. Contact 703/836-7114, email certification@ABCop.org, or visit ABCop.org/individual-certification.
July 2 WEBINAR
Co-OP Tutorial. Noon ET. For more information, visit www.AOPAnet.org.
ABC: Prosthetic Clinical Patient Management (CPM) Exam. ABC Testing Center, Tampa, FL. Contact 703/836-7114, email certification@ABCop.org, or visit ABCop.org/ individual-certification.
AOPA Virtual Coding and Billing Seminar. For more information, visit www.AOPAnet.org.
Prior Authorizations: What Have We Learned and What You Need To Know. 1 PM ET. For more information, visit www.AOPAnet.org. WEBINAR
June 4 WEBINAR
Co-OP Tutorial. Noon ET. For more information, visit www.AOPAnet.org.
ABC: Written and Simulation Certification Exams. ABC certification exams will be administered for orthotists, prosthetists, pedorthists, orthotic fitters, mastectomy fitters, therapeutic shoe fitters, orthotic and prosthetic assistants, and technicians in 350 locations nationwide. Contact 703/836-7114, email certification@ABCop.org, or visit ABCop.org/individual-certification.
Documentation: Working With Your Referral Source. 1 PM ET. For more information, visit www.AOPAnet.org.
August 11 WEBINAR
PrimeFare Central. Tulsa Renaissance Hotel and Convention Center. In-Person Meeting. For information, contact Cathie Pruitt at 901/359-3936 or email email@example.com, or Jane Edwards at 888/388-5243 or email firstname.lastname@example.org. Visit www.primecareop.com.
MAY 2021 | O&P ALMANAC
Prosthetics Clinicians Corner. 1 PM ET. For more information, visit www.AOPAnet.org.
AOPA Monthly Webinar. 1 PM ET. For more information, visit www.AOPAnet.org.
September 9–11, 16–18
AOPA National Assembly. The 2021 National Assembly will be held in Boston, September 9-11. In addition to the in-person Assembly, we will be offering all the education virtually. This content will be available a week after the Assembly, September 16-18. For more information, visit www.AOPAnet.org.
AOPA Monthly Webinar. 1 PM ET. For more information, visit www.AOPAnet.org.
AAOP. Atlanta, GA. For more information, visit www.oandp.org/events/event_list.asp?DGPCrSrt=&DGPCrPg=2.
New York State Chapter of American Academy of Orthotists and Prosthetists (NYSAAOP) Meeting. Rivers Casino & Resort. Schenectady, NY. For more information, visit nysaaop.org/meeting.
Orthotic & Prosthetic Innovate Technologies Conference. Minneapolis, MN. For more information, go to http://cecpo.com/documents/OrthoAndProstheticTech_2022_1up.pdf.
ISPO 18th World Congress. Now virtual. For more information, contact the ISPO World Congress team at email@example.com or call +49/341-678-8237.
AOPA Monthly Webinar. 1 PM ET. For more information, visit www.AOPAnet.org.
September 29–October 1
AOPA National Assembly. San Antonio, TX. For more information, visit www.AOPAnet.org.
AOPA Monthly Webinar. 1 PM ET. For more information, visit www.AOPAnet.org.
2022 January 9–11
U.S. ISPO Pacific Rim Conference. Waikoloa, Hawaii (Big Island). For more information, visit www.usispo.org.
January 30–February 3
Hanger Live. Dallas, TX.
Let us share your next event!
Phone numbers, email addresses, and websites are counted as single words. Refer to www.AOPAnet.org for content deadlines. Send announcement and payment to: O&P Almanac, Calendar, P.O. Box 34711, Alexandria, VA 22334-0711 or email jburwell@ AOPAnet.org along with VISA or MasterCard number, cardholder name, 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.
Words/Rate 25 or less 26-50 51+
Member Nonmember $40 $50 $50 $60 $2.25/word $5.00/word
Color Ad Special 1/4 page Ad 1/2 page Ad
For information on continuing education credits, contact the sponsor. Questions? Email info@AOPAnet.org.
O&P ALMANAC | MAY 2021
STATE BY STATE
Regional News Updates from Illinois, Kansas, Michigan, New York, Texas, and Washington
Each month, State by State features news from O&P professionals about the most important state and local issues affecting their businesses and the patients they serve. This section includes information about medical policy updates, fee schedule adjustments, state association announcements, and more. These reports are accurate at press time, but constantly evolve. For up-to-date information about what is happening in your state, visit the Co-OP at www.AOPAnet.org/ resources/co-op.
NEW MEMBER RESOURCE ALERT
AOPA has invested in a new resource that allows us to track legislative and regulatory activity related to O&P in every state. We will be updating the state pages on the AOPA Co-OP with alerts as they arise.
Following the Jan. 1, 2021, rollout of the Medicare Competitive Bidding Program for off-the-shelf orthoses, Illinois HB 62 proposes the creation of the Pharmaceutical and Durable Medical Goods Committee to negotiate the prices of pharmaceuticals and durable medical goods with suppliers or manufacturers on an open-bid competitive basis for the state. The Illinois Society of Orthotists and Prosthetists opposes this legislation and seeks to exclude custom orthotic, prosthetic, and pedorthic (OPP) care based on definitions in the Illinois OPP Practice Act and the qualified OPP provider language.
The updated BCBS Kansas policy titled “MicroprocessorControlled Prostheses for the Lower Limb” has been flagged by AOPA and members in Kansas. AOPA is currently reviewing the policy and discussing a possible medical review request with the insurer. Please visit the AOPA Co-OP for updates.
Submit Your State News To submit an update for publication in the State by State department of O&P Almanac, email awhite@AOPAnet.org.
MAY 2021 | O&P ALMANAC
Members in Michigan and the Michigan Orthotic and Prosthetic Association have reported that they are in the beginning stages of seeking legislation that would limit the amount that any payor could undercut Medicare/ Medicaid rates for prosthetic coverage.
Become an AOPA State Rep.
If you are interested in participating in the AOPA State Reps network, email awhite@AOPAnet.org.
Working closely with members and on behalf of the New York AAOP Chapter, AOPA has conducted two successful letter-writing campaigns designed to garner support for a Medicaid fee schedule raise, resulting in more than 300 letters written to New York state representatives. For details, visit the New York page of the AOPA Co-OP.
In Texas, HB 2134—Relating to Coverage for Childhood Cranial Remolding Orthosis Under Certain Health Benefit Plans—has been referred to the Insurance Committee and scheduled for a public hearing, the date of which is to be determined. AOPA will continue to share updates on HB 2134 via the AOPA Co-OP.
A bipartisan coverage bill has been introduced in Washington, co-sponsored by eight Republicans and nine Democrats. HB 1427 specifies that health plans issued or renewed on or after Jan. 1, 2022, must provide coverage for benefits for prosthetics and orthotics that are at least equivalent to the coverage provided by the federal Medicare program, and no less favorable than the terms and conditions for the medical and surgical benefits in the policy.
CALL FOR VOLUNTEERS
O&P Leaders Build your network. Advance your career.
Give back to the profession. Volunteer for a Workgroup and/or Committee.
The American Orthotic & Prosthetic
AOPA VOLUNTEER COMMITTEES | WORKGROUPS
Association (AOPA) has opened its annual
Assembly Planning Committee
call for volunteers and we need your
Coding and Reimbursement Committee
talent. Employees of all AOPA member
Diversity, Equity, and Inclusion Committee
companies are invited to serve on one of AOPA’s Committees and/or Workgroups.
Government Relations Contributions/Fundraising Government Relations Committee Member Services Committee Operating Performance and Compensation Workgroup Research Committee State Representatives Veterans Affairs Committee
Don’t miss this exciting opportunity to become involved in the O&P profession by supporting AOPA and your colleagues!
Terms of service are two-years and begin December 1, 2021. Most workgroups or committees meet face-to-face at least once per year with monthly conference calls lasting approximately one-hour. Additional time commitments include reviewing materials and work to accomplish the goals of each workgroup or committee. For details about the goals and responsibilities of each workgroup or committee and information on the process, refer to the Call for Volunteers Policy.
APPLICATION DEADLINE: JUNE 30, 2021 Submit your application at www.AOPAnet.org/volunteer. QUESTIONS? Contact Betty Leppin at bleppin@AOPAnet.org or 571-431-0810.
FOLLOW US @AmericanOandP
Join the mission.
Help people regain their freedom of movement. For over 100 years, we’ve researched and developed products to help restore human independence. As a global leader in prosthetics and orthotics, Ottobock strives for excellence and innovation – not only in our products and services, but the people we employ.
Apply today at shop.ottobock.us/careers.