CMS Proposed Rule for Special Payment Provisions and Requirements for Qualified Practitioners
Click here to view the CMS proposed rule for the establishment of special payment provisions and requirements for qualified practitioners and qualified suppliers of prosthetics and custom-fabricated orthotics.
Our Government Relations team has been actively tracking and advocating for key O&P legislation. To briefly recap, there are a few bills that OPGA is tracking that will vastly improve the O&P environment.
• Medicare Orthotics and Prosthetics Improvement Act, S. 829 – which makes effective reforms to O&P requirements and protections for Medicare
• Preserving Access to Modern Prosthetic Limbs Act, H.R. 5045 – rescinds LCD for Lower Limb Prosthetics and promotes a transparent process with stakeholder input outside of agency. (We expect more information to be coming towards the end of the month on this matter.)
• Audit and Appeals, Fairness, Integrity and Reform in Medicare (AFIRM) Act, S. 2368 – Restrains RAC audits and addresses excessive delays at the ALJ level.
• Hospital Improvement Program (HIP) – Establishes a new RAC reporting system that will provide information on numbers of RAC denials and overturned appeals.
• Prior Authorization, H.R. 2437 – Designs proper PA structure in which professionals will not be subjected to post-payment audits after PA approval.
OPGA and VGM Government Relations have been working closely with congressional offices as these bills have been developed and make their way through the legislative process. In order to ramp up our efforts we are calling on our OPGA members to play a key role in building up a grassroots coalition of O&P professionals to build strong relationships with congressional offices. These relationships play a major role in the legislative process and assert that good policy is being enacted that will positively affect professionals and patients. Building these grassroots efforts includes numerous ways to get involved including in-district meetings, location visits with elected officials, support letters, and much more.
Click this link to find your members of Congress: http://cqrcengage.com/vgm/app/lookup?0&m=83425
OPGA and VGM Government Relations are here to offer expertise and guidance through what may seem like a complex process, and most professionals find it to be extremely beneficial and easier than they originally thought. Below are just a few of the many tools that Government Relations is here to assist you with engaging with your elected officials:
• Schedule and coordinate in-district congressional meetings or on-site visits with your member of Congress
• Offer personalized coaching sessions to walk you through conducting a meeting or interacting with the elected official, and accompany you on your visit
• Craft policy talking points specific to your district and concerns
• Provide educational materials to help you learn about the legislative process
Contact OPGA and let us know how we can help you!
View the Ossur webinar that explains the impact of the proposed LCD for lower limb prosthetics here: https://attendee.gotowebinar.com/recording/6258267721516596226
Medicare DME MAC's have recently proposed a new Local Coverage Determination for lower limb prosthetics that if becomes policy, would negatively impact the access to care and restrict what prosthetists could provide for their patients. These radical changes that are proposed will have a devastating impact on the 2 million amputees currently living with limb loss in our country today. WE NEED YOUR HELP!
1. Please sign a White House petition to stop this proposal by Medicare.... If you have more then one email address please sign it for each email address, then pass it on to your friends, family, co-workers, and anyone you know. Here is the link: https://petitions.whitehouse.gov/…/rescind-medicare-proposa…
A Summary from Ossur is below:
The draft LCD has too many changes to easily address in a single post, but we want to flag a preliminary "top 10" from that document. (For ease of reference, our Top 10 list is in the same order these items are discussed in the draft LCD. Please also note that this is not a comprehensive list of the proposed changes.)
OPGA/VGM Host Event for O&P Advocate Rep. Duckworth
Congresswoman Tammy Duckworth joined OPGA/VGM representatives and thought leaders in Chicago for the Premier Plus LIVE educational event.
The event in-part served as a fundraiser for Rep. Duckworth as she seeks election to the U.S. Senate to represent the state of Illinois.
Rep. Duckworth looks forward to representing her constituents and vowed to continue supporting the O&P profession. With the burden that audits have put on providers, she will continue her passion to spearhead legislative solutions that can improve the current regulatory environment that is harming O&P providers and Americans with disabilities.
“Tammy knows first-hand the issues facing O&P providers and the patients being served,” said Tom Powers, VGM Government Relations. “In her short time as a congresswoman, she has been instrumental in crafting bill language and working diligently across party lines to pass important bills in support of our providers.”
Also attending the event was U.S. Small Business Administration Deputy Ombudsman Yolanda Swift. Swift spoke of the ways that the SBA has been helpful with issues facing O&P providers. She also thanked OPGA and VGM Group for all of the work they have been doing to share the information and issues that are affecting their members.
“The SBA, with Yolanda’s guidance, is aware of the negative impact that audits have inflicted on our members,” said Powers. “They are committed to addressing these concerns with CMS and will be hosting several events this summer to discuss regulatory issues facing DMEPOS including a hearing and two roundtables.”
On April 27, 2015, the OPGA team accompanied two members to Washington, D.C., to deliver powerful testimonies at the Small Business Administration (SBA) National Regulatory Fairness Hearing in Washington, D.C. Their task was to describe how audits are negatively impacting their small businesses and ask for change.
An O&P Practice that Dates Back to the Civil War
John Tyo from Syracuse Prosthetic Center (SPC) described how the business is deeply engrained in the fabric of America and their Central New York community. The company’s history stretches back to 1866 – over 149 years and six generations. Tyo’s involvement with the company comes from his father, a veteran who at 19 left his leg behind in Italy during World War II. Today Tyo’s son and son-in-law are nationally recognized certified prosthetists.
150-Year Celebration in Jeopardy
RAC contractors have consistently found prosthesis to be “fraudulently” provided for patients, despite the fact that doctor’s attestation, third-party verification, photos and video evidence prove the level of prosthetic system provided is appropriate.
Having the proper prosthesis allows patients to live healthy and active lives.
RAC contractors initially attempted to audit 14 prosthetic patients ($160,000), when they were legally allowed to audit just four.
Over $90,000 has been recouped from five cases. SPC’s total profit for FY2010 was just $46,720.
The high-dollar prostheses, ones with the highest potential for commission, were audited most.
SPC has occurred legal and accounting fees to face the enormous challenge.
SPC is waiting for cases to be reviewed by an Administrative Law Judge. The current wait is 2.5-4 years.
Proper celebration of 150 years of business is difficult to do when employees wonder from month to month whether they will continue to be in business.
Email Congress now by clicking here.
John Tyo and local amputee meet with Sen. Schumer’s health legislative aide.
OPGA Member Sara Beck and Her Freedom of Information Act Request
Sara Beck, the office manager and appeals specialist for San Joaquin Orthotics & Prosthetics (SJOP), is using her smarts and legal training to take on the unfair RAC audit system. In her testimony, Beck described how CMS has “stripped my business of its financial stability and devalued our compassion and dedication to their beneficiaries.” Beck made two Freedom of Information Act (FOIA) requests to CMS to determine whether a national provider was receiving the same audit treatment as their small business.
FOIA Requests Show Unjust Disparities
San Joaquin Orthotics & Prosthetics:
- In a two-year period, they received over 55 CMS audits totaling over $250,000.
- Their claims ranged from $8000-$40,000
- 85 percent of the claims were for high-dollar prosthetics
The National O&P in the Area:
- In the same two-year period was audited by the RAC just 13 times, for a mere $6,251.
- Their claims ranged from $20-$400.
- No high-dollar prosthetic claims were audited in a five-year period.
Sara Beck gives her testimony.
SBA’s Response –Will Work with OPGA to Rectify Concerns
Tyo and Beck’s testimonies were emotional and resonated as most of the SBA board members approached the OPGA group after the hearing with additional questions and concerns. Brian Castro, the National Ombudsman of the SBA and the Region III Regulatory Fairness Board, promised to continue communicating with OPGA to help rectify the concerns with the audit program. They conveyed a commitment to working with OPGA and Members to make changes to help small businesses and independent providers remain in business to take care of their patients.
***Many Thanks to John Tyo of Syracuse Prosthetic Center and Sara Beck of San Joaquin Orthotics & Prosthetics for their excellent testimonies.***
OPGA and VGM Members teamed together for the hearing.
What Can You Do?
Please take just a few minutes to email Congress today. It’s a simple four-step process.
Step One – Click here to get started. You will be redirected to a page where you will need to take two actions.
Step Two – The first action is to click Take Action to message your senators. U.S. Senators need to hear our support for Senate Bill 829, the Medicare Orthotics and Prosthetics Improvement Act of 2015. When you click the Take Action button, you’ll see a pre-written letter. If you would like to edit the letter to tell your own story, you may do that as well.
Step Three – Fill in your name, physical address and email address and click Send Message.
Step Four – Return to the main page to take the second action - to message your representatives. Under “Support HR 1530 and HR 1526” click the Take Action link. Then repeat steps two and three with the form provided.
Also, here is a document with talking points we created for Congressional Members.