The Dominoes Begin to Fall

falling dominoesThe publication of the Medicare draft LCD and Policy Article for Lower Limb Prostheses obviously caused great concern within the O&P community as evidenced by the huge show of support during the August 26th public meeting and rally at DHHS headquarters.  A consistent question that has been heard since the release of the policy is: How long will it take to see the affects of this policy trickle down into the private insurance market.  The answer to that question, unfortunately, is not long at all.

In its most recent medical policy bulletin published in August of 2015 and effective for dates of service on or after October 1, 2015, United Healthcare, currently the largest insurer in the United States, issued a policy statement that states, “The use of vacuum pumps for residual limb volume management and moisture evacuation systems among amputees is unproven and not medically necessary due to insufficient clinical evidence of safety and/or efficacy in published peer-reviewed medical literature”.  A remarkably similar statement in the Medicare draft LCD and Policy Article states that claims for HCPCS codes L5781 and L5782 which describe vacuum based residual limb volume management and moisture evacuation systems will be denied as not medically necessary because there is “insufficient published clinical evidence to support these claims.”  While I try to never be pessimistic about things, the timing of this policy decision by United Healthcare, along with the similar language that appears in both policies forces me to question the genesis of the United Healthcare coverage decision.

During its meeting with high ranking CMS and HHS officials on the afternoon of August 26th, AOPA expressed its deep concern that while the policy published by Medicare was done so as a draft, with no bearing on current claims for lower limb prostheses, private insurers would be quick to use language in the draft to justify policy decisions regarding coverage of lower limb prostheses.  Unfortunately, It appears that AOPA’s concern was well founded.

AOPA has provided CMS and HHS with a copy of the recent United Healthcare policy bulletin to drive home the point that the language from the draft LCD and Policy Article is already being picked up by private insurers, and has also reached out to United Healthcare directly to discuss this policy decision.  As this issue progresses, AOPA will provide updates regarding the future coverage of vacuum based volume management and moisture evacuation systems by Medicare and private payers.

The decision by United Healthcare to declare vacuum based volume management and moisture evacuation systems will not be the last decision that is based on language in the Medicare draft LCD and Policy Article.  It is important that you review any policy bulletins you receive that appear to limit coverage of prosthetic services and notify AOPA immediately so we may address these issues promptly.

AOPA’s Take.  Where you go…..When you need to know!!!

Amputees Take Their Message to the Street!

Protest PictureLast Wednesday, I experienced one of my proudest moments as an employee of AOPA and a member of the O&P community. I witnessed the full power of the amputee community as they stood up and proclaimed enough is enough and demanded recognition as folks who, despite their missing limbs, must be treated fairly by the government and the Medicare program.

Wednesday morning began with the scheduled public meeting to provide input on the draft Local Coverage Determination (LCD) and Policy Article governing Medicare coverage of lower limb prostheses that was published simultaneously by the four DME MACs on July 16, 2015.  As those of you that are familiar with the draft LCD and Policy Article are aware, the proposed policy would severely limit access to clinically appropriate and medically necessary lower limb prostheses for Medicare beneficiaries.  I was honored to sit in the room with more than 400 people and 80 speakers who felt the need to express their concern over the potential ramifications of the draft policy on Medicare beneficiaries and amputees covered by private insurance.  While the draft policy is a Medicare only policy, many private insurers adopt Medicare policy as their own, greatly expanding the universe of amputees potentially affected by the proposed policy changes.  Speaker after speaker took the podium to discuss their very personal stories and express their grave concern regarding how the proposed policy may restrict their access to quality prosthetic care.  To say these stories were emotionally moving is an understatement.  The bravery and willingness to share very personal issues in order to influence the direction of the proposed policy was simply awe inspiring.

After the public meeting, more than 150 individuals boarded buses for a trip to Washington, DC to participate in a rally in front of the Department of Health and Human Services building.  Amputees and non-amputees joined together and made sure their voices were heard for almost 3 hours as they marched, rallied, gave speeches, and literally stood on a soap box to deliver the message to CMS that artificial limbs are not a luxury.  Toward the end of the rally, representatives from AOPA, the O&P Alliance, and the Amputee Coalition met with CMS Acting Administrator Andrew Slavitt as well as other high ranking CMS and DHHS officials to reiterate the concerns of the O&P community regarding the potential impact of the draft LCD and Policy Article.  Reports from this meeting indicate that it was extremely positive and that CMS will be discussing the draft LCD and Policy Article further with its DME MAC contractors.

As the rally ended and the folks that had dedicated their personal time and money to participate in the days events headed home, I took a moment to reflect on the day.  Never in my twenty years in the O&P industry have I seen such a coordinated effort of the amputee community, the O&P community, and the groups that represent them, to make sure their voices were heard.  I can truly say that on Wednesday, August 26, 2015, I have never been prouder to work for and be part of the O&P community.

AOPA’s Take.  Where You Go….When You Need to Know!

Proposed Medicare Lower Limb Prosthetic Policy-What Does It Mean For The Future of O&P?

CMSOn August 16th, the four DME MACs published a proposed Local Coverage Determination (LCD) and Policy Article that will govern the future provision of lower limb prosthetic service to Medicare beneficiaries.  To say that the proposed policy, in its current form is a “game changer” is an understatement.  The proposed policy represents the first major change to lower limb prosthetic policy in over 20 years and is almost a complete revision of the existing lower limb prosthetic policy.

AOPA has significant concerns regarding the potential impact this policy will have on AOPA members and, more importantly, Medicare beneficiaries who rely on Medicare to cover their artificial limbs.  A multi-level strategy for creating a professional, clinically based response to this proposed policy is being developed and will be communicated to AOPA members in the near future.  This strategy will include coordinated efforts among all industry groups to ensure that we are communicating with “one voice”, representing the entire O&P industry, not just the individual businesses or professionals each group separately represents.  The strategy will also include the education and mobilization of Medicare beneficiaries, who must be their own advocate in ensuring the continued access to high quality, medically appropriate prosthetic care.

As an initial step, AOPA has prepared an executive summary of its major concerns regarding the proposed policy along with a more comprehensive detailed analysis of the potential impact of the proposed policy along with opinion on how the policy can be improved to ensure continued access to medically necessary prosthetic care for Medicare beneficiaries as well as provision of that care at reasonable rates for providers.  Both the executive summary and the comprehensive analysis may be viewed on AOPA’s website at:

AOPA will continue to post information and resources regarding how you can provide your own input regarding the proposed policy revision as they are developed.

AOPA’s take on this issue is that the proposed policy revision is one of the most important issues the O&P industry will face.  The proposed policy, if finalized in its current form, will have a profound impact on your ability to provide high quality, medically necessary prosthetic services to your patients.  Failure to take notice and participate in the public comment process would be a disservice to yourself and your colleagues in the O&P profession.

AOPA’s Take.  Where you go….when you need to know!




Recent Jurisdiction D Audit Results Tell A Story

headacheNoridian Healthcare Solutions, who serves as the Jurisdiction D DME MAC has recently released the results of its ongoing pre-payment review for spinal orthoses described by L0648 and L0650 and knee orthoses described by L1832 and L1843.

From January until April, 2015, 154 claims for L0648 were reviewed and 101 were denied representing an overall claim denial rate of 66%. In the same timeframe, 153 claims for L0650 were reviewed and 106 were denied representing an overall denial rate of 69%.  The top reasons for denial were no documentation submitted, invalid proof of delivery, no dispensing or detailed written order, and no documentation supporting the need for replacement.
Based on the denial rates, Noridian will continue its pre-payment review for these codes.

From January until April 2015, 89 claims for L1832 were reviewed, all of which were denied representing an overall denial rate of 100%. In the same timeframe, 93 claims for L1843 were reviewed and 92 were denied for an overall denial rate of 99%.  The top reasons for denial were no documentation submitted, lack of documentation supporting the medical need for a custom fitted device rather than an OTS device, no documentation of knee instability or ambulatory status of the beneficiary, and invalid proof of delivery.  Based on the denial rates, Noridian will continue its pre-payment review for these codes.

AOPA’s take on the results of both of these pre-payment reviews is that the DME MACs are now actively enforcing the revised proof of delivery requirements published in February, 2015 as well as the policy requirement regarding the need to document the specific modifications that were made to a device in order to justify billing it as custom fitted.   These are both recent, but significant changes to coverage policy and are actively contributing to higher claim denial rates during pre-payment reviews.

O&P providers must continue to be diligent in making sure that policy requirements are met, regardless of whether they or AOPA believe they are fair.  Failure to comply with these policy changes will only contribute to higher error rates which in turn lead to additional pre-payment reviews.

AOPA’s Take,  Where you go…..When you need to know!

Advocacy in NY State Leads to Elimination of One Limb per Lifetime Policy

AdvocacyAn 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!!!

New NSC Contractor Announced

CMSOn 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!!

DME MACs Revise Policy for Coding of Custom Fitted Orthoses

CMSThe 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!

Update on OTS Orthoses and Competitive Bidding

comp biddingOn April 21, 2015, the Centers for Medicare and Medicaid Services (CMS) announced the product categories and Metropolitan Statistical Areas (MSAs) that will be included in the next round of DMEPOS Competitive Bidding, now being called Round 1 2017. While it appeared that off the shelf (OTS) orthoses were being considered for inclusion in competitive bidding, OTS orthoses were not among the eight product categories identified for inclusion in the Round 1 2017 competitive bidding program.

AOPA’s Take on this issue is that while this is certainly a positive development, it does not mean that OTS orthoses will not be included in competitive bidding at some point. The descriptor changes that were implemented in 2014 to clearly distinguish OTS orthoses from custom fitted orthoses certainly indicate the intent of CMS to eventually include OTS orthoses in competitive bidding at some point in the future.

AOPA will continue its ongoing discussion with CMS regarding its concern about the continued expansion of what are considered OTS orthoses through regulatory and policy based channels rather than following the appropriate notice and rulemaking process required by the Administrative Procedures Act.

AOPA’s Take. Where you go….When you need to know!

AOPA Members Take On Capitol Hill

CapitolLast week, over 120 AOPA members came to Washington, D.C. to participate in the 2015 AOPA Policy Forum. This is the one time each year that AOPA members have the opportunity to join their colleagues and meet with their elected officials in Washington. Whether folks were participating for the first time or were seasoned veterans, the excitement in the air was palpable. AOPA’s message was strong and its members were ready to deliver it to their representatives and senators.

The two day program began with a “primer” day in which attendees heard from various speakers who offered hints on how to approach lawmakers and their staff regarding the issues at hand. Rep. Brett Guthrie (R-KY) addressed the audience as the keynote speaker for day 1 and discussed the importance of actively participating in the legislative process. Several other presentations and discussion panels prepared the attendees for their congressional visits scheduled for the next day.

Day two began with remarks from Sen Charles Grassley (R-IA) who stressed the importance of lawmaker visits and the impact that they have as well as his strong belief in the O&P Medicare Improvements Act, a bill which he proudly serves as co-sponsor of. After Senator Grassley’s remarks, participants received their schedules and headed off to meet with their legislators,

Feed back on the visits was extremely positive as most Policy forum participants indicated that the lawmakers and staffers they met with were receptive to AOPA’s message.

AOPA’s Take on the 2015 Policy Forum is that it was an extremely successful event that put AOPA members directly in touch with their congressional representatives. As Senator Grassley reminded the attendees, the 1st amendment does not only guarantee freedom of speech, but also guarantees the right to “petition for a governmental redress of grievances.” Participation in the AOPA Policy Forum allowed folks to exercise that right and bring AOPA’s message directly to Capitol Hill. If you have not yet participated in an AOPA Policy Forum, next years event will be here sooner rather than later. Active participation in your government is crucial to the success of your O&P practice.

AOPA’s Take. Where you go……when you need to know!

Recent Medicare Audits Bring Mixed Results

Audit checklist on a deskThe results of recent Medicare audits of O&P claims bring a mixed message of relative success in some areas and continued deficiency in other areas. While improvements are always encouraging, the continued high error rates, specifically those involving claims for spinal orthoses indicate that there is still work to be done in understanding what Medicare expects and requires in order to reimburse O&P providers for legitimate services to Medicare beneficiaries.

The good news is found in recent audits results published by Jurisdiction B regarding its longstanding pre-payment review of high error rate DMEPOS claims. In the 4th quarter of 2014, Jurisdiction B reviewed a total of 5,893 claims of which 3,327 were denied, resulting in a claim error rate of 56.46%. While this error rate is still unacceptably high, it does continue the positive trend that has developed over the last year which began with a 68% claim error rate in the 1st quarter of 2014. Continued diligence by providers in making sure all of the documentation required for Medicare payment is contained in the patient’s medical record should drive the claim error rate increasingly lower with the hope that it is ultimately low enough to discontinue the pre-payment review.

The not so good news is the continued high claim error rates for spinal orthoses reported by both Jurisdiction B and Jurisdiction D. Jurisdiction B recently reported 4th quarter 2014 results that indicated a 95.80% error rate on spinal orthosis claims and Jurisdiction D reported a 4th quarter 2014 error rate of 99% for spinal orthosis claims. These high error rates clearly show that providers either do not understand the documentation requirements necessary for Medicare payment for these services or that the documentation requirements are so unreasonable that it is virtually impossible for providers to gather the necessary documentation to support the medical need for the spinal orthoses they are providing.

AOPA’s Take on this issue is mixed, just like the audit results. The continued downward trend of denials for high error rate services in Jurisdiction B is certainly encouraging but the error rates for spinal orthoses that are almost at 100% continues to be a source of frustration and confusion. We simply cannot be that bad when it comes to documentation for spinal orthoses.

AOPA encourages its members to review the LCD and Policy Article governing Medicare coverage of spinal orthoses and make sure that all of the documentation requirements are being met. especially the relatively new requirements that state that providers who bill for custom fitted orthoses instead of off the shelf orthoses document the specific modifications that were required to properly fit the orthosis to the patient.

AOPA will continue to monitor audit results published by the DME MACs and will continue to fight for the fair treatment of O&P providers.

AOPA’s Take. Where you go…..When you need to know!!!