Crisis in Orthotic and Prosthetics Care Delivery

Posted by on Aug 1, 2013 in General |

Important information for prosthetics patients and their doctors

prosthetics newsletter

Read this article and more in the Alltech Summer 2013 Newsletter. Click here to download.

An extraordinary event transpired May 13, 2013: The American Orthotic and Prosthetic Association (AOPA), primary business confederation of prosthetic limb and orthopedic brace providers in the United States, sued the O&P industry’s primary funding source, the Centers for Medicare and Medicaid Services (CMS), in federal district court.

This drastic step came only after 20 months of a non-stop double-barreled assault on the long-accepted business customs and reimbursement policies under which O&P providers have delivered assistive devices to patients covered by Medicare and Medicaid and which threatens to put many dedicated and once-successful practices out of business; in fact, some have already succumbed.

amputee care fort worth dallasWhat has become nothing less than a full-blown crisis for the orthotic and prosthetic specialty was launched with the August 2011 release of a Department of Health and Human Services Office of Inspector General report entitled “Questionable Billing for Lower Limb Prosthetics.”

Subsequently, CMS contractors issued a letter to all physicians enrolled in the Medicare program stating that only notations in the physician’s record would henceforth be acceptable for establishing the medical necessity, and thus the reimbursement, for prosthetic or orthotic claims. The formerly fully acceptable documentation of the attending prosthetist or orthotist, based on a thorough patient evaluation and accumulated years of specialized training and experience, was suddenly deemed inconsequential. In truth, board-certified prosthetists and orthotists typically possess far more insight as to the appropriate prosthetic or orthotic
device for a given patient than does the doctor who refers that patient for O&P care.

But that was just the beginning. CMS then unleashed an army of bounty-hunters known as “recovery audit contractors” (RACs) to reclaim previously approved reimbursements to O&P providers for claims submitted under the then-existing guidelines, ostensibly to combat supposed fraud and abuse but in reality to shore up a suddenly curtailed budget in the run-up to implementation of the Affordable Care Act, which includes a promise to extract $750 billion over 10 years from Medicare providers.

By arbitrarily overturning claims already reimbursed, the RACs have withheld payments to O&P providers for current approved claims, creating for many a substantial, in some cases fatal, financial blow.

Yes, overturned reimbursements and now-predictable initial denials of new claims can be appealed, but the appeals process is now taking as long as two years. Most O&P practices are small businesses, many of which lack the resources to survive a extended delay in receiving payment for their services.

What Does This Mean for Patients

prosthetics dfwAs challenging as the current state of affairs is for O&P providers, it can be considerably worse for Medicare patients, who now face potentially long delays in receiving a new prosthesis or orthosis while all now-necessary extra documentation is gathered and in many cases will no longer be approved to receive the most appropriate componentry for their condition.

Whereas O&P practices formerly could rely on CMS reimbursement for most prosthetic limbs or braces they provided, no such assurance exists today. When a claim is disapproved, either the
patient assumes responsibility or the O&P provider must bear the cost; neither option is satisfactory.

Moreover, because CMS auditors are regularly disallowing claims for advanced components that can help patients achieve their maximum potential, many providers have concluded they have no choice but to select less-expensive, basic alternatives with resulting diminished benefit to the patient.

For instance, in some parts of the country claims for limbs tailored to the capabilities of CMS Functional Level 3 amputees (“community ambulator” — ability or potential to walk with a variable cadence and traverse most environmental barriers) are almost automatically
rejected, even with perfect documentation. As a result, these amputees now must make do with less-expensive Functional Level 2 (“limited community ambulator”) componentry, including low-performance prosthetic feet, basic knee units for above-knee amputees, and less-innovative socket designs.

Initially, CMS took aim at lower-limb prosthetics. Now the focus has expanded to spinal orthoses (see page 3 article), and claims for AFOs (ankle-foot orthoses) and KAFOs (knee-ankle-foot orthoses) are soon to receive similar treatment.

What Can We Do? What Can You Do?

amputee care dfwAs long-time providers of O&P services, our company and our practitioners are as dedicated as anyone to curbing fraud and abuse in our specialty and not wasting government funds. But, as the AOPA lawsuit charges, the HHS OIG report alleging widespread fraud and abuse is seriously flawed and based on numerous erroneous conclusions regarding how O&P care is prescribed and administered. In short, it vastly overstates the “fraud” and “abuse” in our field.

For example, the OIG report’s authors misunderstood that it is not unusual that most Medicare amputees may not see the “referring physician” who first prescribed their prosthetic care because that physician is commonly the surgeon who amputated their limb and has no other participation in their case. Why such a fundamental misconception made it into the final report raises troubling questions.

We are hopeful the AOPA lawsuit will be successful and in time a corrective judgment will help alleviate the prevailing crisis in O&P care delivery. Another potential resolution is action in Congress. O&P practitioners and practice owners are visiting and contacting their elected officials to apprise them of the CMS actions and the need for relief. We also encourage our readers and patients to contact their senators and representatives about this highly important issue.