An intensive, three month long advocacy effort by O&P professionals in New York state has lead to a significant victory through a reversal of policy in the New York State Healthcare Exchange benchmark plan that limited coverage for artificial limbs to one prosthesis, per limb, per lifetime. In a letter dated May 17, 2015, Donna Frescatore, the Executive Director of the New York State Health Exchange indicated that the benchmark plan will be altered, effective January 1, 2016 to include coverage of the cost of repairs to and replacement of artificial limbs for both children and adults covered by the plan.
This reversal of an overly restrictive and unfair policy that limited coverage to one prosthesis per limb, per lifetime was the direct result of the tireless advocacy efforts of O&P practitioners in New York, who received direct support in their efforts by the Amputee Coalition and the National Association for the Advancement of Orthotics and Prosthetics, as well as broad support from industry groups such as AOPA and the O&P Alliance. The coalition that challenged this policy was extremely well organized and sent a very powerful message to lawmakers and policymakers in New York who had the authority to make this change, that beneficiaries must be treated fairly and have reasonable access to exchange based healthcare benefits that are required under the Affordable Care Act.
AOPA’s Take on this victory is that it is a valuable lesson regarding the value of advocacy in today’s healthcare environment. The folks in New York recognized that the one limb per lifetime restriction was extremely detrimental to beneficiaries looking to the healthcare exchange to purchase adequate health insurance. they were able to mobilize an incredible advocacy campaign and effect change in a very short amount of time.
AOPA continues to support grassroots advocacy across the country and is encouraged by the victory in New York. The only way to create change is to make sure that your voice is heard.
AOPA’s Take. Where You Go…..When You Need to Know!!!
On May 13, 2015, the Centers for Medicare and Medicaid Services (CMS) announced the final award of the National Supplier Clearinghouse (NSC) contract to NCI Information Systems, Inc. a Reston, VA based IT firm that will administer the contract through AdvanceMed, a wholly owned subsidiary that also holds several CMS contracts to serve as regional Zone Program Integrity Contractors (ZPICS). The contract, worth $52 million, is for one base year and up to 4 additional option years.
Palmetto GBA, who has held the NSC contract since the creation of the NSC almost 20 years ago, filed a protest of the original contract award which was dismissed by the Government Accountability Office, clearing the way for the final award of the NSC contract to NCI.
CMS did not provide any specific information regarding when the transition of the NSC contract will occur. AOPA will provide any information regarding the transition as it is announced.
AOPA’s take on this issue is that this may be a bit of a bumpy road, especially in the beginning of the transition period. Theoretically, the transition should be seamless to the provider community but Palmetto GBA has had 20 years to refine their processes, which still remain far from perfect. NCI based its proposal on its ability to provide streamlined provider enrollment with increased focus on keeping questionable suppliers from enrolling in the Medicare program. While its proposal was successful, in terms of achieving the contract award, the transition to a new contractor always creates the potential for problems and delays in processes. While Palmetto GBA has been far from perfect, NCI is an unknown entity which creates a lot of uncertainty regarding their ability to improve on the processes developed by Palmetto GBA.
AOPA will continue to monitor this issue and communicate any updates as they are announced and implemented.
AOPA’s Take. Where you go……When you need to know!!
The four DME MACs have revised a joint coding bulletin regarding the proper coding of custom fitted prefabricated orthoses versus off the shelf (OTS) orthoses. The revised bulletin reiterates the need for “substantial modification by a qualified individual” when billing for a custom fitted orthosis as opposed to an off the shelf orthosis. This is nothing new and is simply a re-statement of what has been existing policy for several years. The revised bulletin does add a new twist however. It states that if a HCPCS code is identified as prefabricated but does not have a corresponding code that describes the same product delivered as an OTS orthosis, it can only be used to bill orthoses that are supported by documentation of substantial modification to the orthosis performed by an individual with expertise in fitting. If this documentation does not exist, or the substantial modification was performed by a person without expertise in fitting, the orthosis must be billed with the appropriate miscellaneous code (L1499, L2999, L3999) and the supplier must indicate that the orthosis was delivered as an OTS item in the narrative field on the claim form.
The Medicare LCDs for spinal orthoses, AFOs/KAFOs, and knee orthoses have all been updated, effective May 1, 2015, to incorporate the language of the revised coding bulletin.
AOPA’s take on this issue is that this “clarification” represents a major shift in policy regarding the proper coding of custom fitted orthoses. If you are providing a custom fitted orthosis and expect to receive reimbursement from Medicare, you must ensure that documentation supports not only the need for whatever modifications were required to obtain a proper fit of the device but that the modifications were performed by a certified orthotist or other medical professional that is deemed qualified to perform the modifications. Failure to do so may lead to unnecessary and costly claim denials.
A link to the revised coding bulletin published by the DME MACs may be found at the link below.
AOPA’s Take. Where you go……When you need to know!