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O&P VISIONARY:
Eve Lee, MBA, CAE, AOPA Executive Director PG.14
REIMBURSEMENT IN O&P:
A CHANGING OF THE TIDE?
PG.4
A Retrospective Analysis of CROW Appointment Frequency PG.12
Tech Tips: The Rigors of O&P Technician Training Programs WWW.AOPANET.ORG
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Vol. 28 • No. 2 | Spring Issue 2019
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COVER STORY
04
Reimbursement in O&P: A Changing of the Tide? What are the challenges related to the current O&P payment model based on the L-code system, and what could be done to improve the system and ensure orthotists and prosthetists are properly reimbursed for their time and expertise as well as the devices they provide? Frank Bostock, MBA, CO; Jeffrey M. Brandt, CPO; Stephanie Greene, Esq.; and Heather Smith, PT, MPH, share their thoughts on these topics.
Research & Presentations 12
Ruthie H. Dearing, MHSA, JD, explains how students at Spoke Falls Community College train to become O&P technicians.
A Retrospective Analysis of CROW Appointment Frequency By Claire Kilpatrick
14 O&P Visionary Eve Lee, MBA, CAE, AOPA Executive Director, discusses recent indictments and fraudulent schemes related to off-the-shelf orthoses.
O&P News | Spring Issue 2019
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COVER STORY
REIMBURSEMENT IN O&P:
A Changing of the Tide?
F
or many years, the O&P profession has grappled with the challenges of an outdated payment model that does not always support the provision of care necessary for the best patient outcomes. O&P professionals routinely justify low margins on some delivered services and devices because they can balance the accounts receivables with the margins on other deliveries. Reimbursement for many O&P services continues to shrink—and in the best-case scenarios, it remains static. O&P News asked various O&P professionals to share their insights and expertise on the current reimbursement processes.
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O&P News | Spring Issue 2019
COVER STORY
MEET OUR CONTRIBUTORS The following individuals contributed responses to this article:
Frank Bostock, MBA, CO, is Southwest region vice president at Hanger.
O&P News: In your opinion, what are the biggest challenges with the current payment model under the L-code system? Heather Smith, PT, MPH: Obviously, there are limitations to today’s system in which we bill codes and are paid on the volume of services. Clearly, there are limitations to the codes themselves and the valuation of those codes. The current system does not take into account the outcome of those services, and so high-value services are reimbursed the same as low-value services. I think there is a lot of opportunity as we move to value-based payment for providers to create payment structures that reward the outcome of service, including improvement in function and patient satisfaction. Jeffrey M. Brandt, CPO: As a result of the coding system not evolving and becoming more adept at quickly evaluating the efficacy of new technologies, it is stifling innovation and causing confusion in the commercial payor world as to why
Jeffrey M. Brandt, CPO, is chief executive officer at Ability Prosthetics & Orthotics Inc.
Stephanie Greene, Esq., is compliance officer at Ability Prosthetics & Orthotics Inc.
Heather Smith, PT, MPH, is director of quality at the American Physical Therapy Association.
more providers are using more miscellaneous codes than ever before. Because the current system has not evolved, I believe it has dissuaded inventors and manufacturers from developing newer products that contain benefits and features outside of the existing L-code descriptors. In my opinion, we have as much product research to support the technological benefits to the patient as we’ve ever had as a profession, and we don’t have an L-code system with the corresponding capability to evaluate, accept, reject, or eliminate products and descriptors to meet the demand, pace, and impact of the clinical and product advances. Frank Bostock, MBA, CO: The biggest challenge for the O&P profession under the current L-code system payment model is that L codes only reimburse individuals for the delivery of products—and as such, certified orthotists and prosthetists, as healthcare professionals, are not compensated for the patient-care services that they provide to their patients beyond the (Continued on page 6)
O&P News | Spring Issue 2019
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COVER STORY
delivery of a product. Subsequently, it is important for the O&P profession to pursue including Current Procedural Terminology (CPT) patient-care billings in their practices for the patientcare services that they provide that are within their scopes of practice and are not included in the labor component of the delivery of a product that is bundled within the Health-Care Common Procedure Coding System (HCPCS) reimbursements. If the O&P profession does not pursue adopting billing CPT codes, then the O&P profession will remain in its product paradigm in the eyes of its payors, referral sources, and patients. As a supplier of O&P products, the O&P profession finds that many of the products that O&P professionals provide have become commodities and are now readily available on the internet through nontraditional suppliers and providers. The availability of O&P products through nontraditional and non-O&P industry delivery models will provide patients and payors alternative sources for purchasing O&P products, including the Amazons of the world, wherein through a smartphone app a patient can take a picture of his or her
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O&P News | Spring Issue 2019
leg and send it to an online provider who will fabricate a custom knee brace and have it at the patient’s doorstep in a matter of days, with online fitting and care instructions. As such, certified orthotists and prosthetists will find their roles as product providers diminishing, and O&P will be challenged to survive in a product-only health-care delivery model. Today, as health-care providers, certified orthotists and prosthetists assist their patients in improving the quality of their lives not through selling them products, but rather through knowing what products and patient-care services combined will provide them with increased mobility and independence, and the best possible cost-effective outcomes. Stephanie Greene, Esq.: The current L-code system, while defined by Medicare as a fee-for-service model, more closely resembles a type of limited global capitation system that doesn’t really have the potential “upside” for O&P providers. Under global capitation, a single payment is made to cover the cost of a predefined set of services delivered to a patient. The lower a provider keeps its amount or
costs of service, the better the profit. We generally think of global capitation as something like a set monthly fee paid to a skilled nursing facility (SNF) or fees paid to a Medicare Advantage Plan, again to cover all services provided to the patient. For O&P providers, our fee-forservice system is very similar to a global capitation model except it is limited in scope to a single type of service. We receive a “single fee” for an item delivered (the argument is that it is a “fee-for-service model”), but that single fee is to pay for all services provided to the patient, not just the single episode of delivery to the patient. The single fee covers the encounters for evaluation, measuring, fabrication, and fitting. It also covers the follow-up services for modifications. Unlike the SNF or Medicare Advantage example, O&P has limited ways to impact the number of services or costs associated with servicing the patient. The current payment model also has an additional downside: commercial payors’ reliance on Medicare coverage determinations. Commercial payors use the same code set as CMS and often reference or specifically follow the same coverage guidelines as CMS and the durable medical equipment Medicare administrative contractors (DME MACs). Since commercial payors do not assign their own HCPCS codes to an item or new technology, we must rely upon CMS for recognizing new technology and assigning the item its own HCPCS code, and then a fee schedule. Unfortunately, the process for obtaining a new HCPCS code is antiquated and fraught with obstacles. The result is very few new technologies are recognized within the HCPCS system. The difficulty in obtaining an HCPCS code also has led to fewer manufacturers even attempting to obtain an HCPCS code for new devices. For instance, in 2007 there were 171 HCPCS applications, with only 35 approved for new codes. In contrast, in 2017 only 78 applications
COVER STORY
were received (and only 68 of them were for new codes). Out of the 78 applications, only seven new codes were approved. This represents a 60 percent decline in applications during a 10-year period where new technological developments within the O&P industry were on the rise. When CMS does not issue an HCPCS code for a specific device or technology, suppliers must use a miscellaneous or not-otherwise-classified code, generally referred to in the profession as a “99” code. There are two distinct problems with 99 codes. First, many commercial payors take a stance that new technologies classified with a 99 code are experimental and investigational, and thus noncovered. Second, the O&P profession is at the mercy of often one-sided contract language for determining fee schedules for 99 codes. We have seen a trend in commercial payors, and Medicaid payors, to propose fee schedules based on a percentage above the manufacturer invoice, and often the proposed percentage is in the range of 5 to 10 percent. Commercial payors tend to be very reluctant to negotiate very far from their offered fee schedule, resulting in a “take it or leave it” approach offered to many in the O&P profession. Other payment terms are based upon the manufacturer suggested retail price (MSRP), which may not consider a single product with a single MSRP, but multiple lines of 99 HCPCS codes used to describe the product’s components. Additionally, many O&P items do not have MSRPs, or the MSRPs do not consider all of the services that must be covered by the payment for the single item (returning again to our global capitation issue). To summarize and answer the original question, the biggest challenges with the current L-code system are (1) a lack of fair compensation for the entirety of the services provided when using a single fee-for-service model and (2) the chilling effect the current HCPCS system has on
recognizing new technology. Without the recognition of new technology and an available market for the technology, we ultimately stifle the development of the technology all together. The impact of the current payment system therefore extends far beyond the prosthetist or orthotist but rather reaches the manufacturer, the inventor, and, ultimately, the patient. O&P News: Do you believe O&P clinicians should be able to bill for their time and expertise? Brandt: Absolutely. Our profession has sanctified its educational requirements over the past 20 years to [require] a master’s level degree. Given this level of education, combined with residencies, board exams, and, in many states, licensure, practitioners should be able to bill and be appropriately reimbursed for the care they provide. We, as a profession, through outcomes measures, are increasingly quantifying the patient-care portion that accompanies the devices we provide. Our profession and billing foundation were once predicated on the device we provided, but as science and research
have better informed us, we now know that the care we provide, alongside of the manufactured device, is at least as important and many times the differentiator in helping a patient transition to using [the device] and actually achieving the outcome all parties were shooting for. Bostock: Yes. Are certified orthotists and prosthetists product suppliers, or are they knowledge-based health-care professionals? Does it make a difference? A difference as it relates to how CMS, insurance payors, referral sources, and patients view certified orthotists and prosthetists? I believe that it does. The perceptions of patients, payors, and referral sources of the O&P profession ultimately define the profession as it relates to the care certified orthotists and prosthetists provide their patients and how they are compensated as healthcare professionals. CMS, payors, referral sources, and patients are the ones that create the paradigm for our profession, and, unfortunately, it is a paradigm that currently defines O&P practitioners as suppliers, vendors, and product sales reps—providers of products. Certified orthotists and prosthetists are the only (Continued on page 8)
O&P News | Spring Issue 2019
7
health-care professionals that do not bill CPT codes for the care that they provide to their patients. Other healthcare professionals bill HCPCS codes for the devices that they provide and CPT codes for the patient-care services that they provide to their patients, and certified orthotists and prosthetists should join the ranks of other health-care professionals and bill HCPCS codes when they provide their patients with products and bill CPT codes for the patient-care services that they provide to their patients that are within their scope of practice. The American Board for Certification in Orthotics, Prosthetics, and Pedorthics (ABC) defines ABC-certified orthotists and prosthetists as health-care professionals specifically educated and trained to manage comprehensive orthotic and/ or prosthetic patient care. Under this definition there are not any references to the profession as vendors, suppliers, product sales reps, or just fitters of products—rather, [ABC] states that certified orthotists and prosthetists are educated and trained to manage comprehensive O&P patient care. If certified orthotists and prosthetists are educated and trained to provide comprehensive O&P care to their patients, they should bill for the care that they provide to their patients. Greene: Yes. O&P is a profession. A profession is generally defined as a paid occupation that involves prolonged training and a formal qualification. Fifteen states have licensure requirements, and three more states require accreditation from a nationally accepted accrediting body. Additionally, Congress passed Section 427 of the Benefit Improvement and Protection Act (BIPA), which instructed CMS to take the steps necessary to limit the payment of prostheses and custom orthoses to qualified providers and suppliers. Congress, and 18 state legislatures, have recognized and solidified our industry as a profession. CMS’s payment system
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O&P News | Spring Issue 2019
should be updated to likewise recognize the health-care treatment provided by the O&P profession. The knowledge and expertise of a prosthetist and orthotist is used during each visit with a patient, and as a profession we provide health care during our interactions with our patients. It is appropriate for prosthetists and orthotists to be compensated like other healthcare professionals, such as physicians or even physical or occupational therapists. O&P News: Is there a current payment model that would work better for O&P? If so, how would this model work for O&P? Brandt: Potentially. We are already paid in a bundle payment. If the current payment system could be modified or improved to capture more clinical episodes of care and subsequent closely related outcomes, the current payment model might survive. The payment model would allow, for example, multiple check sockets or sockets or even trial units to make more highly predictive patient use or efficacy decisions. Like the
Merit-Based Incentive Payment System, payment levels should be commensurate with level of outcome and quality of care provided—not simply payment for devices. Bostock: Yes. Other health-care providers, such as physicians, physical and occupational therapists, dentists, optometrists, podiatrists, and athletic trainers, provide and bill for patientcare services using CPT codes and provide and bill for medical products using HCPCS codes, in many instances including orthotic and prosthetic devices. Certified orthotists and prosthetists who also provide patient-care services and medical devices only bill for the products and not the patientcare services that they provide to their patients. The O&P profession should adopt the same billing practices the other health-care providers use wherein the products that they provide to their patients are billed using HCPCS codes, and, when patient-care services are provided, they bill using CPT codes. (Continued on page 10)
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COVER STORY
Greene: Out of the current compensation methods used by CMS, I believe the most appropriate compensation method would be copying the physician CPT system, mimicking the evaluation and management (E/M) coding patient visit system. E/M coding is based on three key components: history, physical, and medical decision making. For instance, an office visit has five different levels, or E/M codes, depending upon the complexity of the evaluation. A similar type of system could be instituted within the O&P profession, compensating a prosthetist or orthotist based upon the number and complexity of services provided to the patient during a specific visit. In addition to providing compensation for the treatment provided during office visits, prosthetists and orthotists should still receive compensation for the actual prosthetic or orthotic device provided to the patient. This again is in line with how physicians are compensated. When the physician provides the patient with a device or other equipment, the physician is able to bill for the actual item provided with the item’s HCPCS code. [For the provision of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), the physician must have a separate DMEPOS provider number.] By mimicking the physician system, prosthetists and orthotists would be compensated for the health-care services and treatment they provide to patients. The compensation would be based upon the actual services provided and needed by a patient, compensating more for the complex cases and less for others. O&P News: Do you believe that O&P should separate from durable medical equipment (DME)? If so, why? Brandt: Yes—provided it can be done correctly and with recognition of the care component. It is clear that “true” O&P care is often defined as long-term usage
10 O&P News | Spring Issue 2019
or the need for a custom device and treatment approach, and those devices require thoughtful and knowledgeable provisioning and long-term usage oversight as well as maintenance and replacements. DME products/devices are largely an acute usage-type of product requiring very minimal clinical skills. They are often most effectively provided immediately following a physician’s office visit for efficiency and thoroughness as it relates to the physician’s treatment approach for that patient’s visit. Bostock: Yes. Certified orthotists and prosthetists should be recognized as knowledge-based health-care professionals, just like other health-care professionals—such as physical therapists, physicians, and podiatrists that also provide patient-care services, and O&P and DME products. Greene: Yes. Most of the DME services are limited to the provision (or delivery) of equipment used by the patient. Except for limited circumstances like complex rehabilitation wheelchairs, the DME provider does not evaluate the
patient or provide health-care treatment. The knowledge and training of many DME providers is product specific and is based around being able to instruct the patient on the use of the item. This is distinct from the O&P profession. We evaluate the health-care needs of a patient and develop a treatment plan for the patient. To do so, we are required to have extensive knowledge and education on the physical body, and knowledge of how to treat deformities and ailments impacting the body. The O&P industry is fighting to be viewed as a profession and to distinguish the provision of a prosthesis and custom orthosis from the “delivery” of a piece of equipment. We are not demonstrating how to use a CPAP machine or mailing diabetic testing strips to a patient, but instead we are evaluating the patient’s physical needs and developing a specific treatment for the patient. We are a profession of healthcare providers, and we cannot fully be viewed and treated as such while we are grouped together with and held to similar requirements as DME suppliers. While those services are important and needed within our health-care system, they are distinct from the services provided by prosthetists and orthotists. O&P News: Some believe that patients have the most to gain from a payment model that adequately accounts for the services provided by O&P clinicians; can you provide any insight or examples of why this is the case? Smith: The move to value-based payment will benefit patients. As cost and outcomes data becomes more available, patients will be able to choose highvalue providers for their care. Brandt: I would largely agree but also I believe the clinicians and support staff at the O&P practice would largely
benefit from a payment model shift to fee-for-value. It would presumably allow for practices to move more in sync with a patient’s clinical needs as dictated by the pathology as opposed to not being able to provide something in a critical timeline because of an L-code quantity or administrative procedural issue.
and prosthetists assist their patients in improving the quality of their lives not through selling them products, but rather through knowing what products and patient-care services combined will provide them with increased mobility and independence, and the best possible cost-effective outcomes.
Bostock: Today, the O&P profession places a greater emphasis on the patient care and rehabilitative services provided by certified orthotists and prosthetists for their patients, and not just on the products provided. The O&P profession has a unique body of knowledge that no other health-care profession has, that interfaces patient-care skills with in-depth knowledge of componentry and materials that enable O&P professionals to assist their patients in achieving their health-care goals and improving their quality of life. Today, as health-care providers, certified orthotists
Greene: I believe a proper payment model protects the patient by ensuring the patient receives all of the care necessary to obtain the best outcome possible. You can open any newspaper on any given day and find an article about the decreasing quality of health care due to the increased pressures placed on health-care providers. Physicians are having to see more patients in a day due to the decreased revenue received for each service. With the increase in volume, patient advocacy groups have argued there is a risk for mistakes and inadequate care.
Under our current payment system, the more time or visits spent with a patient, the less revenue the prosthetist or orthotist receives for the care. This inherently places the prosthetist and patient at odds. While we all hope a prosthetist or orthotist would never purposely provide less than quality care because of the compensation model, the reality is the clinician must continue to bring in new patients and provide new services to receive compensation. This means that extra visits to try different technology or follow-up visits to verify the best fit are harder and harder for prosthetists to afford. Likewise, the amount of time a prosthetist can spend with each patient on a given day is lessening. By compensating the prosthetist for the actual health care provided, you protect the patient by removing the inherent conflict that currently exists between care and compensation.
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Research & Presentations
A Retrospective Analysis of CROW Appointment Frequency By Claire Kilpatrick
C
harcot Restraint Orthotic Walker (CROW) orthoses represent a unique and complex category of orthotic management. CROW orthoses affect the patient’s functional gait pattern, by restricting motion in the encompassed Charcot joint(s), as well as offload any existing ulceration and provide protection to underlying soft tissue. Due to the complex and multifaceted care required, it is reasonable to anticipate appointments will be required beyond device delivery. Understanding the distribution and frequency of these appointments has the potential to help clinicians better understand the follow-up needs of the patient and identify clinical factors that may influence appointment follow-up frequency. This retrospective analysis attempted to characterize the frequency and distribution of appointments required by CROW patients at Scheck & Siress over a twoyear period. In the Scheck & Siress electronic medical record (EMR) and scheduling system, there are four primary appointment types related to CROW patient care: casting, delivery, adjustments, and follow-ups. For the purposes of this analysis, the frequency of followups and adjustments were combined to create a single follow-up value. This is because when scheduling appointments,
12 O&P News | Spring Issue 2019
there is no clear delineation between the care provided at an adjustment versus a follow-up. This review utilized the per-patient frequency of these appointment types from all Scheck & Siress locations from Dec. 1, 2016, to Dec. 1, 2018. The initial data included appointment types and frequencies for 329 patients. To be eligible for inclusion, patients must have had at least one casting and at least one delivery appointment for a CROW orthosis within the two-year period; 170 patients in the Scheck & Siress system met this inclusion requirement.
Data Collection and Analysis Collectively, the 170 patients had 207 casting appointments (32.14 percent), 218 delivery appointments (33.85 percent), and 219 follow-up appointments (34.01 percent), for a total of 644 patient encounters. There was an average of 1.22 ± 0.47 casting appointments per patient, 1.28 ± 0.61 delivery appointments per patient, 1.29 ± 2.25 followup appointments per patient, and 3.79 ± 2.57 total appointments per patient. In all, 46.47 percent of the 170 patients required no adjustments, and 53.53 percent one or more follow-up appointments (Figure 1). In addition, 36.47 percent of the 170 patients required two total appointments over the two-year
Research & Presentations
period; 77.65 percent required four total appointments or less, and 22.35 percent required five or more appointments (Figure 2). The findings of this retrospective analysis indicate that the majority of patients require at least one followup appointment corresponding with a casting and delivery appointment, potentially indicating that the scope of care often extended beyond device delivery. Variations in the frequency of total and follow-up appointments perhaps highlight an existing dichotomy among different clinical presentations of CROW patients and the necessary care protocol. Factors contributing to this dichotomy may include stage of Charcot progression, general patient compliance, existence of comorbidities, severity and existence of ulceration, or practitionerspecific follow-up protocol. This preliminary analysis did not distinguish between patients requiring one casting and delivery appointment with those requiring greater than one casting or one delivery appointment in the two-year time frame. Additionally, there was not a required order of appointments for inclusion; therefore, it is possible that follow-ups included applied to a previously delivered CROW orthosis prior to casting for the new CROW. It also is possible that the appointment-type descriptor was not appropriate in all patient encounters, leading to the mislabeling of the services provided during the appointment.
Conclusion Moving forward, this initial analysis may be helpful in setting the stage for a larger discussion regarding the standard frequency and distribution of follow-up appointments. Based on the findings presented here, it is beneficial for practitioners to investigate not only follow-up appointment frequency but the timing relative to the initial device delivery.
Figure 1 Distribution of adjustment/follow-up appointment frequency per patient from Dec. 1, 2016, to Dec. 1, 2018.
Follow-up Appointment Frequency (12/1/16-12/1/18)
16% 9%
46% 29%
n
0 Appointments
n
1 Appointment
n
2 Appointments
n
3 or more Appointments
Figure 2 Distribution of total appointment frequency per patient from Dec. 1, 2016, to Dec. 1, 2018.
Total Appointment Frequency (12/1/16-12/1/18)
22%
37%
16% 25%
n
2 Appointments
n
3 Appointments
n
Further research should be done to establish the relationship between patient-specific characteristics and follow-up frequency. Improving this understanding enables clinicians to better predict the needs of their patient, provides valuable insight into the patient
4 Appointments
n
5 or more Appointments
factors that indicate a need for increased follow-up care, and may help inform the development of a standard follow-up care protocol. Claire Kilpatrick is a prosthetic/orthotic resident at Scheck & Siress.
O&P News | Spring Issue 2019
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O&P Visionary
Eve Lee, MBA, CAE,
AOPA Executive Director The recent indictments in fraudulent Medicare schemes are a step in the right direction
O
n March 28, 2019, AOPA released a statement strongly criticizing the use of lead generation marketing to deliver orthotic devices to patients covered by Medicare or other types of insurance. This practice puts patients at risk as it does not provide clinical care by a qualified orthotic professional and could lead to providing medically unnecessary orthoses with no instruction on proper fitting, care, or use. On April 9, less than two weeks later, the U.S. Department of Justice (DOJ) announced multiple indictments against 24 individuals responsible for more than $1.2 billion in losses to the Medicare program through fraudulent schemes involving the use of lead generation marketing to deliver orthoses that were not medically necessary or not wanted by the beneficiary. Simultaneously, CMS announced the immediate suspension of Medicare payments to 130 Medicare-enrolled durable medical equipment suppliers suspected of participating in the scheme and responsible for more than $1.7 billion in Medicare claims and more than $900 million in Medicare reimbursement. AOPA is highly encouraged by both the DOJ indictments and the administrative action taken by CMS. We are
14 O&P News | Spring Issue 2019
AOPA Executive Director Eve Lee, CAE, right, and Immediate Past President Michael Oros, CPO, LPO, FAAOP, at the 2018 AOPA National Assembly
hopeful that this sweeping action will drive this criminally negligent activity out of the orthotic and prosthetic marketplace. AOPA first expressed concern about potential fraud and abuse involving off-the-shelf (OTS) orthoses when CMS identified a complete set of OTS codes that, according to its own policy,
required little to no fitting by properly certified or licensed orthotic professionals to deliver and bill to Medicare. We have continued to voice our concern at every opportunity. Most recently, AOPA has pursued legislation that will ensure that Medicare patients continue to have access to clinically appropriate orthotic care delivered by properly educated, certified, and/or licensed professionals. AOPA, with the support of its O&P Alliance partners, is preparing—the Medicare Orthotics and Prosthetics Patient-Centered Care Act—which contains several provisions that would further guarantee that criminal elements such as those uncovered by DOJ will no longer be able to use OTS orthoses to generate illegal profits through exploitation of the Medicare program and its beneficiaries. AOPA is currently meeting with key members of Congress to discuss potential sponsorship. During the 2019 AOPA Policy Forum, which took place in Washington, DC, May 7-8, AOPA members met with members of Congress to educate them on the issue and ask them to take action that protects patients. Eve Lee, MBA, CAE, is executive director of AOPA.
STATE NEWS
State by State
The latest news from Colorado, Kentucky, Minnesota, New Mexico, and New York
O&P News talks to O&P professionals about the most important state and local issues affecting their businesses and the patients they serve. This column features information about medical policy updates, fee schedule adjustments, state association announcements, and more.
Colorado AOPA has received reports from several members indicating significant delays in the prior authorization process for orthotics and prosthetics by Colorado Medicaid. Additionally, reports indicate that Colorado Medicaid is no longer covering two liners. AOPA is planning an outreach effort to Colorado Medicaid on behalf of our members with respect to both of these issues. Please let us know if you have experienced either of these issues in your facility. We would like to have as many AOPA members on the record as possible to assist with this outreach effort.
Kentucky Kentucky House Bill 224 has passed in the House with a unanimous vote and is pending a hearing before the Senate Health and Welfare Committee. The bill stipulates that the Kentucky Department of Medical Services and Medicaid managed-care organizations (MCOs) shall reimburse prosthetic, orthotic, and durable medical equipment suppliers at no less than 100 percent of what is determined in the state Medicaid durable medical equipment (DME) fee schedule. Medicaid MCOs are required to cover, at a minimum, the same HealthCare Common Procedure Coding System codes and the same quantities of medical supplies, equipment, or services as are established through the Kentucky Medicaid program’s DME fee schedule. Additionally, the Department of Medical Services or a Medicaid MCO shall not include a review for medical necessity for equipment that has received a prior authorization, prepayment review, or postpayment review. Once a prior authorization is granted, an MCO or fee-for-services plan is required to continue authorization, at a minimum, for the same amount, duration, and scope until the authorization period ends regarding those equipment, supplies, or services. Medicaid MCOs
are required to reimburse suppliers of orthotics, prosthetics, or DME for manually priced items at the manufacturer’s suggested retail price minus 15 percent when there is a suggested retail price. If no suggested retail price is available, the MCO is required to pay at the invoice price plus 20 percent. The Department of Medical Services must require the allowable timeframe for claim submissions to be equal to the timeframe for any discrepancy during the Medicaid MCO’s audit or recoupment period.
Minnesota An appropriations bill to fund an advanced digital technology center for orthotics and prosthetics has been introduced in Minnesota. H.F. 537 would appropriate $15 million from the general fund to the commissioner of employment and economic development for a grant to Century College for development of an advanced digital technology center for orthotics and prosthetics to provide workforce training and education on high-end digital technologies, with a focus on innovation and industry collaboration. This is a one-time appropriation and is available until expended. (Continued on page 16)
O&P News | Spring Issue 2019
15
New Mexico New Mexico House Bill 70, Insurance Fairness for Amputees, passed through the House chamber and is now on its way to the Senate for consideration. The Amputee Coalition is encouraging O&P stakeholders living in New Mexico to take a moment and contact their New Mexico state senator to ask for support. The organization has set up a letter-writing campaign that can be accessed at www.amputee-coalition.org.
physician or other licensed health-care provider. The coverage is subject to annual deductibles and coinsurance but consistent with other benefits in the policy. It does have language that states, “Such coverage may be limited to one prosthesis for the life of the policy.” New York Assembly Bill 4812 also has been introduced. The legislation requires health insurance companies to provide coverage for the replacement of a prosthetic device in the event it is lost or stolen. It also requires replacement of
New York Two bills pertaining to prosthetic coverage have been introduced in the state of New York. New York Assembly Bill 5328 has been introduced, which requires individual, group, or corporate policy to include coverage for the purchase of prosthetic devices to compensate for the loss of a limb and is prescribed by the treating
a prosthetic limb for a child until the age of 19 as often as required or prescribed by the child’s physician. EDITOR'S NOTE: To submit an update for publication, please email awhite@AOPAnet.org. For up-to-date information about what's happening in O&P in your state and to join the conversation, visit the AOPA Co-Op.
NE
W
Make Your First Impressions Count With Customized Polo shirts, Scrub tops, and Lab Coats for your O&P staff
Create an attractive business image, promote your brand, and foster team spirit with AOPA’s new Apparel Program. To order your apparel, go to
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AOPA Polo Shirts–Now for Sale Order AOPA polo shirts for your office! The shirts are black with a white AOPA logo. Moisture wick, 100 percent polyester. Rib knit collar, hemmed sleeves, and side vents. The polos are unisex but the sizes are men’s M-2XXL. $25 plus shipping. Order in the bookstore at bit.ly/aopastore.
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AOPA is partnering with Encompass Group, a leading provider of health-care apparel, to offer members special prices on customized polos, scrub tops, and lab coats.
16 O&P News | Spring Issue 2019
POLO TS SHIR
B SCRU TOPS
LAB COAT
!
AOPA Celebrates Health-Care Compliance & Ethics Week November 3-9, 2019
HE SAVE T
9 NOV. 3-
2019
FOLLOW US @AmericanOandP
Save the Date!
Health-Care Compliance & Ethics Week Make plans to join your AOPA member colleagues in celebrating Health-Care Compliance and Ethics Week (HCEW), November 3-9. In its first year celebrating HCEW, AOPA energized more than 500 members of our community to participate in seminars, educate staff, and share their focus on ethical behavior with their patients and community. AOPA is organizing resources, education, prizes, and more to help your organization participate. With a week-long celebration of compliance and ethics, you have a great opportunity to introduce and reinforce your chosen themes. Your plans will rely in part on your organization’s specific needs, but some basic goals may include:
AWARENESS of the Code of Conduct,
relevant laws/regulations, and other reporting methods, the organization’s compliance and ethics staff, etc.
RECOGNITION of training completion, compliance and ethics successes, etc.
REINFORCEMENT of a culture of
compliance for which your organization strives.
AOPA has developed several free tools and resources to assist you. Visit our dedicated web page for tools, resources and more:
bit.ly/AOPAEthics
DATE
CALENDAR
Meetings & Courses
2019 JUNE 12 Documentation—Understanding Your Role. Register online at
OCTOBER 9 Performance Reviews: How Is Your Staff Doing?. Register
rgleeson@AOPAnet.org.
JULY 10 Target, Probe, Educate—Get To Know the Program & What the Results Are Telling You. Register
DECEMBER 11
online at bit.ly/2019webinars. For
The Holiday Season—How To Provide Compliant Gifts. Register online at bit.
New Codes for 2020, Other Updates, and Yearly Roundup. Register online at
more information, email Ryan
ly/2019webinars. For more
bit.ly/2019webinars. For more
Gleeson at rgleeson@AOPAnet.org.
information, email Ryan Gleeson at
information, email Ryan Gleeson at
rgleeson@AOPAnet.org.
rgleeson@AOPAnet.org.
bit.ly/2019webinars. For more information, email Ryan Gleeson at
NOVEMBER 13
NOVEMBER 3–9 Health-Care Compliance & Ethics Week. AOPA is celebrating
PRACTICE SALES & APPRAISALS
Health-Care Compliance & Ethics
WANTED!
Week and is providing resources to help members celebrate. Learn more at bit.ly/aopaethics.
A few good businesses for sale.
online at bit.ly/2019webinars. For more information, email Ryan
Lloyds Capital Inc. has sold over 150 practices in the last 26 years.
Gleeson at rgleeson@AOPAnet.org.
AUGUST 14
If you want to sell your business or just need to know its worth, please contact me in confidence.
Are You Ready for the Worst? Contingency Planning. Register
Barry Smith Telephone: (O) 323/722-4880 • (C) 213/379-2397 Email: loyds@ix.netcom.com
online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.
SEPTEMBER 11 Veterans Affairs Updates: Contracting, Special Reports, and Other News. Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.
Publisher Eve Lee, MBA, CAE Advertising Sales RH Media LLC Design & Production Marinoff Design LLC
SEPTEMBER 25–28 AOPA National Assembly. San Diego Convention Center. For general inquiries, contact Ryan Gleeson at 571/431-0836 or rgleeson@AOPAnet.org, or visit www.AOPAnet.org.
18 O&P News | Spring Issue 2019
SUBSCRIBE O&P News (ISSN: 1060-3220) is published 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 ymazur@AOPAnet.org. EMAIL ADDRESS CHANGES To update your subscription email address, contact 571/431-0876, fax 571/431-0899, or email ymazur@ AOPAnet.org.
Copyright © 2019 American Orthotic and Prosthetic Association. All rights reserved. This publication may not be copied in part or in whole without written permission from the publisher. The opinions expressed by authors do not necessarily reflect the official views of the publisher, nor does the publisher necessarily endorse products shown in O&P News. The O&P News is not responsible for returning any unsolicited materials. All letters, press releases, announcements, and articles submitted to the O&P News 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. ADVERTISE Reach out to the O&P profession and more than 13,500 subscribers. Engage the profession today. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net.
TECH TIPS
O&P Technician Education & Training By Ruthie H. Dearing, MHSA, JD
E
nter the O&P lab at Spokane Falls Community College (SFCC) and you instantly realize this is not your typical classroom. Individual work benches, strewn with tools of the trade, reveal that each student is diligently crafting some phase of a brace or prosthetic limb. With students enrolling every quarter, there are six different student cohorts operating at varying stages of training. While all of the action may appear disorganized, you quickly recognize that the orchestration of the faculty, coupled with the shared assistance among students, creates a robust learning environment. Throughout the lab, students are refining their skills. Prosthetic technician
students are fabricating transtibial prostheses, while orthotic technician students are finishing thoracolumbosacral orthoses. In the sanding room, a student uses a Trautman router to buff and smooth the socket he is customizing. In the plastic room, the instructor demonstrates how to pull plastic to create an ankle-foot orthosis. Eight hours a day at SFCC, students practice and problem solve, create, and customize in preparation for their future work in the orthotic and prosthetic profession. Students in the technician programs at SFCC benefit from a rigorous and comprehensive educational training experience. The programs are competency based, where each task must
A student works in the Spokane Falls Community College O&P lab.
The large workspace facilitates creativity and problem solving among the O&P technician students.
be successfully demonstrated to meet industry standards, before the student is challenged by the completion of more complex tasks. Each course builds upon the previous course to promote solid foundational knowledge of the tools, terminology, materials, and techniques used every day in O&P practices and facilities. Amidst this hub of activity, it is obvious the students are proud of their work and the career they’ve chosen— confident that the knowledge and skills they’re acquiring will serve them well and benefit future patients. Ruthie H. Dearing, MHSA, JD, is program coordinator at the Spokane Falls Community College O&P Technology Program.
O&P News | Spring Issue 2019
19
#AOPA2019
THE PREMIER MEETING FOR ORTHOTIC, PROSTHETIC, AND PEDORTHIC PROFESSIONALS
In Proud Partnership
Who Should Attend? There will be something for practitioners, physicians, technicians, fitters, students, educational instructors, facility owners, marketing personnel, residents, office managers, billing specialists, researchers, manufacturers, distributors and suppliers of O&P products and services. Come learn about the latest in O&P products, education, legislation, business management and more. It also provides the opportunity to interact with fellow healthcare and O&P professionals from around the world while earning over 40 CE credits.
EARN
40+ CE
S CREDIT
REGISTRATION NOW OPEN Learn more and register at www.AOPAassembly.org
Together we will drive the waves of change. The National Assembly is the most anticipated meeting for orthotic, prosthetic and pedorthic professionals featuring the best clinical, business and technical education worldwide. To ensure you get the most relevant, tailored education presented by PhDs, MDs, prominent researchers, leading practitioners and successful technicians, the Assembly offers five dedicated tracks: orthotic, prosthetic, business, pedorthic and technical education. Additionally, our premier Exhibit Hall showcases products and services from around the world to meet all your patient care needs.
For information about the show, scan the QR code with a code reader on your smartphone or visit www.AOPAassembly.org.
ANA19 4-Pg Brochure.indd 1
AOPA 2019 National Assembly SEPTEMBER 25-28, 2019 San Diego Convention Center 111 West Harbor Drive, San Diego, CA 92101
AOPAnet.org
4/30/19 10:17 AM