Home Services Government Relations

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…

2. After reading the proposed draft here: http://www.medicarenhic.com/viewdoc.aspx…
You can submit comments to the Medical director, Stacey Brennan, M.D. at this email address: DMAC_Draft_LCD_Comments@anthem.com .  You have until Aug. 31, 2015 to submit comments.

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.)

#1: New Definitions

The draft LCD creates new definitions for numerous terms, including "immediate prosthesis,"  "preparatory prosthesis," "definitive prosthesis," "replacement prosthesis," and "Licensed or Certified Medical Professional" (which refers to non-suppliers qualified to perform functional assessments of amputees).

#2: The 3 Types of Prosthetics

The draft LCD prohibits the use of any add-on codes for Immediate (Post-Operative) Prostheses and Preparatory Prostheses. It would also deny "all related additions" if any part of any type of prosthesis is denied as not reasonable and necessary.​

#3: Socket Code Restrictions

The draft LCD limits the use of certain codes when billing for sockets. For example, L5637 and L5650 (total contact) would be denied as unbundling when billed for a molded socket design. Similarly, it would prohibit billing L5668 (molded distal cushion) for any patient using "a liner or insert that incorporates materials that provide cushioning."

#4: Say Goodbye to Elevated Vacuum Systems

The draft LCD declares L5781 and L5782 "not reasonable and necessary" due to lack of sufficient clinical evidence.

#5: Major Foot Code Changes

The draft LCD collapses L5980, L5981, and L5987 into one new code generically describing "dynamic response" feet.

#6: Axial Rotation Code Changes

The draft LCD collapses L5982, L5984 and L5986 into one new code generically describing an "axial rotation unit, with or without adjustability."

#7: Fixed-Ankle Feet Only for K1 and K2 Patients

The draft LCD restricts L5968 to K3 or higher users.

#8: Prosthetic Cover Restrictions

The draft LCD formalizes previous MAC guidance classifying L5962, L5964 and L5966 ("flexible protective outer surface covering" codes) as "rarely necessary," with the sole exception being instances where the user has "special needs for protection against unusually harsh environmental situations."

#9: K Level Overhaul

The draft LCD eliminates any analysis of the patient's "potential" functional level, restricting the K level analysis solely to the patient's actual ability at the time of assessment. It also would automatically make any patient using a walker or crutches a K1 user and any patient using a cane a K2 user.

#10: In-Person Physician Patient Examination Required

The draft LCD requires any patient receiving a definitive prosthesis to undergo an in-person examination by the physician beforethe physician signs the detailed written order. In addition, the physician must both provide a copy of her examination to the prosthetist within 45 days of its occurrence and do so before delivery of the prosthesis. The LCD also lists a comprehensive set of findings that must be included in the in-person examination report.

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.”

To learn more about Rep. Tammy Duckworth visit her website and like her on Facebook.

 

 

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.

Read Tyo’s official testimony.

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.

Read Beck’s official testimony.

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.

Why are RAC Auditors Treating National Entities Differently Than Independent Business Owners?

Like John Tyo and Sara Beck’s testimonies, your story is important and can make a difference!