On November 23, 2015, the Centers for Medicare and Medicaid Services (CMS) released the 2016 Medicare DMEPOS fee schedule. As expected, Medicare fees for orthotic and prosthetic devices will be slightly lower in 2016 than they were in 2015.

The annual update to the Medicare O&P fee schedule is based on a combination of the increase in the Consumer Pricing Index for urban areas (CPI-U) from June to June of the previous year, and the annual Mutli-factor Productivity Adjustment. The CPI-U increased by a total of 0.1{b3e9dd6b2a2b9b0b8877c781f3059c6a19b65fa453cdc02b99584f3fd07dbcf4} from June 2014 to June 2015 and the 2016 Productivity Adjustment was calculated as -0.5{b3e9dd6b2a2b9b0b8877c781f3059c6a19b65fa453cdc02b99584f3fd07dbcf4}. The combination of these two factors will result in an overall decrease of 0.4{b3e9dd6b2a2b9b0b8877c781f3059c6a19b65fa453cdc02b99584f3fd07dbcf4} in the 2016 Medicare O&P fee schedule.

While a decrease in the fee schedule is not unprecedented, the 2016 decrease is the first one since 2011, when the Productivity Adjustment was first introduced as a result of the passage of the Patient Protection and Affordable Care Act (ACA) in 2010.

AOPA members are reminded that in addition to the 0.4{b3e9dd6b2a2b9b0b8877c781f3059c6a19b65fa453cdc02b99584f3fd07dbcf4} decrease in the 2016 O&P fee schedule, sequestration remains in effect for Medicare claims. Sequestration will result in a 2{b3e9dd6b2a2b9b0b8877c781f3059c6a19b65fa453cdc02b99584f3fd07dbcf4} reduction in Medicare reimbursement but as this reduction is not cumulative year over year, it should not be reflected in the net decrease in the 2016 fee schedule.

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

It has been remarkably quiet on the Recovery Audit Contractor (RAC) front for the last 18 months or so. As a result of the original RAC contracts coming to an end and new RAC contract proposals being submitted and reviewed, the number of additional documentation requests (ADRs) have been reduced significantly. CMS advised its original RAC contractors to essentially hold off on issuing new ADRs until new contracts were finalized and implemented. One of these new contracts would establish a single, national RAC contractor who would be responsible for RAC audits on all Medicare DMEPOS, Home Health, and Hospice claims. This contract was initially awarded to Connolly Healthcare who currently serves as the Jurisdiction C RAC contractor for all Medicare claims.  While the contract award was issued in December 2014, a subsequent protest of the award initially delayed its implementation and eventually led to a CMS decision to issue new bids for all of the RAC contracts, including the national contract for DMEPOS, Home Health, and Hospice claims.

On November 16, 2015, CMS announced that while new bids for RAC contracts are being accepted and reviewed, the existing four RACs may continue to perform RAC reviews and may begin to issue additional ADR requests.  This signals an effective end to the moratorium that was placed on new RAC activity in February of 2014.  While it may take a few weeks for the current RACs to put in place the resources to re-start full scale activities, there is no reason to expect that they will not do so as soon as possible.

While this announcement is not an encouraging development, RAC audits are not new to the O&P community and hopefully we have learned some lessons from previous experiences with RAC auditors.  When RAC audits began several years ago, O&P providers faced a new reality as far as what documentation was expected in order for claims to be paid and stay paid.  Hopefully this education has not been forgotten as a result of the slow down in RAC audits and the impact of the RACs becoming more active will be significantly lower.

RAC audits for O&P providers are still limited to a maximum of 10 audits per Tax ID every 45 days.  AOPA encourages everyone to make sure you are aware of these limits and to challenge any requests that exceed the limits.  While nobody is happy to hear that the RACs are back in business, at least temporarily, the lessons of the past should make for a less stressful future.

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

On July 16, 2015, the four DME MACs simultaneously released a draft LCD and Policy Article that proposed major changes to Medicare coverage rules for lower limb prostheses. The proposed changes were so detrimental to the provision of quality prosthetic care for Medicare amputee beneficiaries that the response from all sides of the prosthetic community, from patients, to providers, to researchers and physicians, was instantaneous and unanimous. There was a broad consensus that the draft policy, as it was written, was simply unacceptable and must be rescinded immediately.

Since the release of the draft LCD and Policy Article, AOPA and its partners, including the O&P Alliance and the Amputee Coalition, have worked tirelessly to educate patients, referral sources, Congressional representatives, and CMS officials on the potentially devastating impact the proposed policy would have on the provision of clinically appropriate prosthetic care to Medicare beneficiaries. Highlights of these efforts included more than 1,000 comment letters from O&P facilities, more than 2,000 comment letters from Medicare beneficiaries, an extremely effective public demonstration at the headquarters of the Department of Health and Human Services, support from multiple Congressional offices, multiple meetings and correspondence with high ranking CMS officials, and a “We The People” White House petition that garnered more than 100,000 signatures in 17 days, requiring a formal response from the Obama administration.

Those efforts bore significant fruit yesterday when the White House and CMS simultaneously announced that the draft LCD and Policy Article would not be finalized “at this time.” The announcement went on to explain that an interagency, multi-disciplinary workgroup composed of federal employees would be formed in 2016 that will review existing research and evidence, identify gaps in knowledge, and develop a consensus statement that will be used to help develop future policy.

While AOPA continues to believe that a full rescission of the draft LCD and Policy Article is the most appropriate action to ensure that Medicare beneficiaries continue to have access to the highest quality of prosthetic care, the decision to not publish the draft LCD and Policy Article in final form shows that when many voices cry out in unison, they cannot be ignored.

Despite the fact that many questions regarding the future of Medicare policy governing coverage of lower limb prostheses, It was a good day for O&P!

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