NAAOP Selects Inaugural Fellow: Nicole Ver Kuilen Report on Rehabilitation Trip to China

NAAOP Fellowship Announcement

NAAOP is proud to announce the selection of Nicole Ver Kuilen as NAAOP’s Inaugural Health Policy and Advocacy Fellow for the summer of 2018.  Nicole was selected through a competitive process from a highly qualified pool of applicants.  She begins her Fellowship on May 30th in Washington, D.C. in NAAOP’s national office and will conclude her summer experience on August 8th.

Nicole is a graduate with distinction from the University of Michigan.  She recently completed a 1500 mile triathalon down the coast of California to raise awareness of amputee and prosthetic issues.  She also has extensive academic and work experience in environmental and sustainability issues.  Nicole has a passion for advocacy and O&P policy witnessed by her recent participation in both AOPA’s O&P Policy Forum and the Amputee Coalition’s Washington Fly-In.  Nicole uses a lower limb prosthesis as a result of bone cancer when she was ten years old.

NAAOP’s new fellow will work for the summer in NAAOP’s office, learn about O&P policy and advocacy as well as the broader rehabilitation and disability field.  She will visit a number of O&P organizations including the Academy, ABC, BOC, AOPA, and the Amputee Coalition.  Field trips to several cities will expose her to O&P clinical practice, the business of O&P, and state-based policy and advocacy.  She will also work with coalitions in Washington and advocate directly on behalf of O&P patients and the providers who serve them.

China Visit Illuminates O&P Capacity

On a recent trip to China with a U.S. State Department delegation, Peter Thomas, NAAOP General Counsel, had an opportunity to present to the China Disabled Persons Federation information on the U.S. rehabilitation system, including orthotics and prosthetics.  A site visit of a rehabilitation hospital and its O&P clinical department revealed significant similarities and differences in the care provided in these two countries.  Consistent with the World Health Organization’s Rehabilitation 2030, A Call to Action, and the Convention for the Rights of Persons with Disabilities (CRPD), China has prioritized rehabilitation of persons with disabilities.

The are many opportunities for collaboration between the two counties on these issues in the future and NAAOP will consider its role as follow up discussions develop.

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NAAOP Selects Inaugural Fellow for 2018

The National Association for the Advancement of Orthotics & Prosthetics (NAAOP) is pleased to announce the selection of Nicole Ver Kuilen as the recipient of the inaugural NAAOP Fellowship. “We are thrilled to have Nicole as our first NAAOP Fellow,” said NAAOP President, David McGill, noting that “the entire applicant pool for the NAAOP Fellowship was incredibly strong.”

The 2018 Fellowship is a 10-week program based in Washington D.C. As the NAAOP Fellow, Ver Kuilen will learn about orthotic and prosthetic policy, advocacy, and how NAAOP and other O&P organizations function on behalf of O&P and within the broader rehabilitation/disability policy and advocacy community at both the federal and state levels. NAAOP General Counsel Peter Thomas noted that “Nicole distinguished herself among several superlative candidates for this inaugural NAAOP Fellowship. We only wish we could have accepted all the candidates and hope an expanded Fellowship program in the future will make room for these and other highly qualified individuals.”

Ver Kuilen lost her leg to bone cancer at age 10. She recently completed a 1,500-mile triathlon down the Pacific coast to raise awareness about challenges amputees have accessing appropriate prostheses. She filmed a documentary about her journey and has taken her message to D.C., educating policymakers about these issues. Ver Kuilen graduated with High Distinction from the University of Michigan Ross School of Business in 2013. She has worked at the Clean Energy Coalition, a nonprofit consulting firm in Ann Arbor, Michigan, and also served as Assistant Director for the University of Michigan School for Environment and Sustainability.

When told of her selection as the inaugural NAAOP Fellow, Nicole said, “I am honored to be selected as NAAOP’s inaugural health policy and advocacy fellow. In the 16 years I’ve been an amputee, I’ve realized our amputee community is systematically being denied the appropriate technology and care we need to live our best lives; this isn’t right. I believe, through our collective efforts, we can create the largest movement in America for mobility rights.”

George Breece, NAAOP Executive Director said, “Nicole was the top selection for each of our Fellowship Committee members. She embodies what the next generation of O&P advocates will be. After her Fellowship experience, we believe Nicole will be an even greater O&P advocate and we know we will be a better organization because she was our inaugural NAAOP Fellow.”

For more information contact:
George Breece, NAAOP Executive Director or 910 583 2161

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NEWS FLASH: Injured and Amputee Veterans Bill of Rights (H.R. 2322) gets a US House Veterans Affairs Committee Hearing

On Tuesday, April 17th, the House Veterans Affairs Health Subcommittee held a hearing to discuss several pieces of VA legislation.  One of the bills was H.R. 2322, the Injured and Amputee Veterans Bill of Rights.  The VA Bill of Rights is bipartisan legislation introduced by Congressman Tim Walberg (R-MI).  See Congressman Walberg’s statement before the Subcommittee at

The same bill passed in 2010 in the House but the Senate did not act.  The bill has since been reintroduced several times but recently, the bill took on much greater importance as the VA announced last fall a proposed regulation that would grant the VA the “sole authority” to determine which prosthetist provides care for each veteran, changing over five decades of VA patient choice.

NAAOP has spearheaded this legislation since Tom Guth, C.P., served as President of the organization.  All of the O&P Alliance organizations (AOPA, AAOP, ABC, and BOC) support passage of the bill, as does the Amputee Coalition.  In fact, the hearing coincided with the Amputee Coalition’s Capitol Hill fly-in and several amputees were front and center in the hearing room during the committee’s deliberations on the bill.

In addition, the Wounded Warrior Project and the Paralyzed Veterans of America support H.R. 2322.  The Disabled American Veterans have not taken a position and the Independence Fund is supportive but offered minor amendments to the bill in their written testimony.  The Veterans of Foreign Wars and The American Legion submitted written testimony opposing the legislation but after outreach from NAAOP before the hearing, both organizations were more conciliatory toward the bill in their oral remarks.  NAAOP will continue its follow up with these organizations to ultimately seek their support.

The next step is to continue working with Congressman Walberg and his able staffer, Mac McKinney, to seek a mark-up of H.R. 2322 in the VA Health Subcommittee.  During the hearing, both the Chairman of the Health Subcommittee, Congressman Wenstrup (R-OH), and the Chairman of the full VA Committee, Congressman Roe (R-TN), spoke favorably about the bill.  In fact, Chairman Roe mentioned that he had recently become aware of H.R. 2322 at a VA field hearing in Fayetteville, North Carolina, home to both Fort Bragg and George Breece, NAAOP’s Executive Director, who attended the field hearing.  This bodes well for the future of this legislation in the House.  And then, on to the Senate……

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O&P Policy Roundup

Victory on Diabetic Foot Orthoses:

March witnesses a decision from the Center for Medicare and Medicaid Services (CMS) to retain the same reimbursement level for diabetic foot orthoses that are digitally scanned and fabricated through additive manufacturing as foot orthoses that are physically molded to a patient model.  This is a major decision that sets a very positive precedent for more than twenty other orthotic L-codes where technology has permitted these new manufacturing techniques to replace traditional fabrication methods.  The decision relies on the following explanation:  “The fees for code K0903 are set based on the fees for code A5513 because inserts carved from a digitized scan of the patient’s foot were determined to be comparable to inserts made over a positive model of the patient’s foot.”  A5513 is the existing billing code for diabetic foot orthoses using traditional methods whereas K0903 is the newly-established billing code for diabetic foot orthoses that are manufactured using digital scanning technology.

This positive conclusion resulted from coordinated and proactive efforts by a number of O&P organizations including AOPA, the O&P Alliance organizations, the Amputee Coalition and the American Podiatric Medical Association.  NAAOP was pleased to have participated in these efforts and believes the decision bodes well for future coding and payment decisions involving innovative manufacturing techniques used in the O&P field.

Omnibus Spending Bill Omits Healthcare Provisions:

The O&P Policy Forum hosted by AOPA was well timed this year as Congress prepared to pass an Omnibus Spending bill to fund the federal government through the end of Fiscal Year 2018.  NAAOP joined over 100 members of the O&P community in sending a strong message to Capitol Hill to include in that bill two major provisions, implementation of BIPA Section 427 which links Medicare payment with O&P practitioner qualifications, and clarification of the term “minimal self-adjustment” which defines off-the-shelf orthotics that are subject to competitive bidding.

The $1.3 trillion bill finally passed and was signed into law on March 23rd.  Many health care organizations worked hard during February and March to include a wide variety of health care provisions in this legislative vehicle.  The O&P community was one of them.  In the end, Congress could not agree to include a bipartisan bill to stabilize the Affordable Care Act’s individual insurance markets and, once this provision of the bill was not included, virtually all of the other health care provisions were also omitted from the bill.  The O&P provisions were left out of the bill along with dozens of other non-O&P healthcare provisions that were under consideration by Congress.  NAAOP will continue working with its Alliance partners to eventually pass these provisions, hopefully in the next legislative vehicle that addresses health care issues.

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NAAOP Announces Unique Public Policy
and Advocacy Fellowship

ATTENTION ALL O&P CONSUMERS:  The National Association for the Advancement of Orthotics and Prosthetics (NAAOP) is soliciting applications for its inaugural health policy/advocacy fellowship. NAAOP is a national nonprofit association advocating for consumers/patients requiring orthotic and prosthetic care, as well as the providers who serve them.  The NAAOP Fellowship is a paid, 10-week summer program based in Washington, D.C.  The fellow will learn about orthotic and prosthetic (O&P) policy, advocacy, and how NAAOP and other O&P organizations function on behalf of the O&P community and within the broader rehabilitation and disability policy and advocacy community at the federal and state level.  The fellowship also includes exposure to (1) O&P clinical and business settings, and (2) state-based public policy and advocacy at no cost to the fellow.

One fellow will be selected for the summer of 2018 through a competitive process using the application on the website.  The deadline to electronically submit this application is March 31, 2018 by 12:00 Midnight.  Three finalists will be interviewed via videoconference and one will be selected.  If the finalist selected cannot accept the fellowship for any reason, the next highest ranked fellow will be offered the position.

Selection CriteriaAll applicants must:

  • Personally use a custom fabricated orthosis or prosthesis;
  • Have an interest in public/health policy and advocacy;
  • Demonstrate an interest in advancing O&P care;
  • Have excellent writing, speaking, and analytical skills (see application for additional factors).

The NAAOP Fellow will receive a stipend of $500 per week.  NAAOP will provide the fellow with an office, phone, and computer in its offices at NAAOP’s counsel, the Powers Law Firm, 1501 M Street, NW, Washington, DC 20005.  NAAOP will assist the fellow in exploring inexpensive summer housing options with area colleges for those with no other housing options.  The NAAOP Fellow will be responsible for his/her housing costs.

The NAAOP Fellow will shadow NAAOP’s General Counsel, Peter Thomas, who will assign and oversee the fellow’s health policy and advocacy work.  That work will focus on O&P policy but also include exposure to the broader rehabilitation and disability policy environment.  Other O&P organizations will host the fellow for a day of activities.  The fellow will also be exposed to policy and advocacy speakers, attendance at Congressional hearings, participation in coalition and “think tank” meetings/presentations throughout Washington, and meetings with organizations in the broader rehabilitation and disability field.

Application Deadline:  12:00 Midnight, Saturday, March 31, 2018

Fellowship Selection Announcement:  By the end of April, 2018

Fellowship Term:  10-weeks (late May or early June through early to mid-August)

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Congress Passes O&P Clinical Notes Provision

In the early morning hours today, Congress passed and the President signed a massive budget agreement that sets budget levels for two years, continues to fund the federal government through March 23rd, and sets up a massive omnibus spending bill to fund the federal government through the remainder of fiscal year 2018.  One of the provisions in this bill directly impacts the O&P community:  Recognition of the prosthetists’ and orthotists’ clinical notes as part of the Medicare patient’s record for purposes of determining the medical necessity of O&P care.


‘‘(5) DOCUMENTATION CREATED BY ORTHOTISTS AND PROSTHETISTS.—For purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by eligible professionals described in section 1848(k)(3)(B).’’

This provision addresses a problem that started in 2011 with publication by CMS of a “Dear Physician” letter that stated that the physician’s notes, not the prosthetist’s, determine medical necessity.  This letter, and subsequent CMS guidance, resulted in a raft of unnecessary Medicare denials of O&P claims, many of which still sit at the ALJ level of review awaiting hearings.  The clinical notes of the prosthetist or orthotist will now be recognized along with the records of physicians and other professionals involved with O&P care.  NAAOP expects this provision to impact the reversal rate of Medicare O&P denials in favor of O&P practitioners at all levels of administrative appeal.

NAAOP congratulates and thanks AOPA and its lobbyists for their leadership on this provision, as well as NAAOP’s membership, the O&P Alliance organizations, the Amputee Coalition, and the ITEM Coalition, all of which worked to achieve enactment of this legislation.  NAAOP and the O&P community will continue the fight to enact two additional provisions from the Medicare O&P Improvement Act (S. 1191 and H.R. 2599), namely:

  • Section 7 of the Medicare O&P Improvement Act: This provision clarifies Congressional intent regarding the definition of “minimal self-adjustment,” which defines off-the-shelf orthotics for purposes of competitive bidding.
  • Section 8 of the Medicare O&P Improvement Act: This provision would direct CMS to finally implement long-overdue regulations for Section 427 of the Benefits Improvement and Protection Act of 2000 (BIPA), which links the right to bill the Medicare program for custom fabricated orthotics and prosthetics with the qualifications of the practitioner or supplier. This is an important fraud & abuse and patient protection.
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VA Choice of Practitioner and Medicare Competitive Bidding

Two major issues are heating up in Washington, veterans’ right to choose their O&P practitioner and Medicare competitive bidding of an expanded range of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS).

VA Choice of Practitioner

The VA published a proposed rule in October making the VA the “sole” authority in choosing the O&P practitioner who will provide services to each veteran.  By doing so, VA proposes to fundamentally change the right that veterans have had for five decades to choose the O&P practitioner who best meets their needs, whether that practitioner is a VA employee or a private provider with a VA.  NAAOP strongly opposes this proposed change and will be working with its O&P Alliance partners to maintain veteran choice.

This “right” is included in the Injured and Amputee Veterans Bill of Rights (H.R. 2322), bipartisan legislation introduced by Congressman Tim Walberg (R-MI).  NAAOP is working with Cong. Walberg to advance the bill or, in the alternative, to try to impact the pending VA CHOICE 2.0 legislation.  This bill would make permanent the VA CHOICE program enacted several years ago.  The bill would expand veterans’ choice of private health care providers, exactly the opposite direction than the VA’s proposed rule on prosthetics.  Look for more information as to how NAAOP members can help on these issues in the coming days.

Expanding Medicare Competitive Bidding

On November 2, the Medicare Payment Advisory Commission (MedPAC) hosted a meeting entitled:  Medicare payment policy for non-competitively bid DMEPOS.  MedPAC staff opened the session by presenting the slide deck accessed here. MedPAC reviewed spending trends and pricing accuracy of non-competitively bid DMEPOS.  Staff indicated that across its top 25 DME items, Medicare spending rates had decreased about 50 percent since 2010 while, during the same period, non-CBP Medicare spending had increased by 24%, with no significant negative changes in beneficiary health outcomes.  (Many in the disability and rehabilitation community would argue this point.)  MedPAC’s staff stated that Medicare could have saved approximately $47 million in 2015 if Medicare rates were equal to median private payer rates for off-the-shelf orthotics alone.

The presentation concluded with the issuance of two policy options for the Commission to consider, one to expand the use of CBP to more items of DMEPOS, and to reduce payment rates for certain non-CBP products annually until they are in line with private rates. To protect beneficiaries from adverse balance billing practices, MedPAC recommended placing a cap on balance billing and paying non-participating suppliers 5% less than participating suppliers.  NAAOP will be monitoring this debate closely and will address significant concerns with MedPAC along with its Alliance partner organizations.

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BIPA Section 427 Update and Other Health Care Developments

There were significant developments on health care issues this month, both broad and narrowly focused on O&P Care.  First off, the Senate was not able to muster a majority to pass the so-called Graham/Cassidy ACA repeal and replace legislation, which means that for the foreseeable future, persons in need of orthotic and prosthetic care will be able to access coverage under Medicaid and private, individual insurance.  This is because O&P care is typically considered an essential health benefit under the Affordable Care Act.  In related news, the House and Senate are moving closer to reauthorizing the Children’s Health Insurance Program (CHIP) for a 5-year period.  CHIP covers over 9 million children with health insurance that includes coverage of O&P care.

With respect to BIPA Section 427, CMS announced that it is “withdrawing” the proposed rule published on January 12, 2017, comments for which were due in March.  CMS received over 5,000 comments and the strongest objections came from physicians, PTs, and OTs, who arguably were exempted from the rule by statute.  By mandating that these providers obtain state licenses to provide O&P care or get certified by ABC or BOC, CMS generated tremendous opposition to the proposed rule.  In the end, these organizations overwhelmed CMS and were able to convince the Trump Administration to pull the rule in the name of regulatory relief.

There is no way paint a rosy picture of this development.  After years spent trying to finally get CMS to issue these regulations in final form, this is a significant step backwards.  However, there are some glimmers hope that we hope to build on.  First, the announcement stated that the rule was being withdrawn to “assure agency flexibility in re-examining the issues and exploring options and alternatives with stakeholders.”  We have already communicated with CMS and plan to meet with them soon to discuss how to proceed from here.

Second, this development heightens the need to rally behind passage of the Medicare O&P Improvement Act (S. 1191 and H.R. 2599) which includes provisions compelling CMS to finally issue regulations interpreting Section 427 of BIPA.  The bill explicitly exempts physicians, PTs and OTs, which would remove the majority of the opposition to the rule.  NAAOP will continue to work for passage of the O&P Medicare Improvement Act and seek alternative ways to implement the letter and spirit of BIPA Section 427.

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Congress Returns to Packed Legislative Agenda

Congress Returns to Packed Legislative Agenda

As Congress returns to Washington in the month of September, it faces a daunting set of challenges. The federal debt limit needs to be increased in order for the federal government to continue meeting its financial obligations. The federal government’s agencies need to be funded by October 1, 2017 or the government will shut down, and the State Children’s Health Insurance Program (SCHIP) needs to be reauthorized by the end of September or authority to run SCHIP will expire.

Complicating this packed legislative agenda is the need for federal funding to address the immediate and ongoing needs created by Hurricane Harvey.   The O&P community will be discussing the profession’s response to this colossal storm and seek ways to assist those impacted.  More to follow….

Several orthotic and prosthetic policy issues continue to be front and center for NAAOP.  CMS recently signaled that it may withdraw BIPA section 427 regulations linking provider and supplier qualifications with Medicare billing privileges. While it appears that CMS has not yet made a final decision, NAAOP and its Alliance partners are working hard to ensure that CMS presses forward with final publication of regulations involving this section of the law, which was passed 17 years ago but never implemented in full.

The Interagency Workgroup on Lower Limb Prosthetics, which was convened in the wake of the draft local coverage determination (LCD) for lower limb prostheses is expected to release a consensus statement at some point in the near future.  However, timing on this is still unclear. Once the Workgroup releases its statement, NAAOP will submit public comments on it.

Meanwhile, Congress continues to address O&P legislation by passing in the House legislation to recognize the relevance of prosthetists’ and orthotists’ clinical documentation as part of the patients’ medical records for purposes of determining the medical necessity of submitted claims. NAAOP is working with its Alliance partners to ensure that Congress passes this provision, along with other aspects of the Medicare O&P Improvement Act this year.

NAAOP also continues to work toward passage of the Injured and Amputee Veterans Bill of Rights, H.R. 2322, which is designed to educate veterans of their rights to quality O&P care and enable them to become their own best advocate in securing such care.

Finally, NAAOP acknowledges and congratulates AOPA on its 100th Anniversary, a true milestone.  We are also very proud to recognize our own 30-year anniversary as NAAOP. Our unending gratitude goes out to our members and supporters who have enabled us to speak on behalf of O&P practitioners and the patients they serve for the past three decades.

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Major Legislative Developments Impact O&P Care

Two major legislative efforts impacted orthotics and prosthetics in July as the House adjourned for their August recess and the Senate delayed their break to proceed to critical votes on other matters.

  1. ACA Repeal and Replace: The Senate debated whether to repeal and replace the Affordable Care Act at length and voted on several different versions of the bill.  Other than the “motion to proceed” with debate on the overall subject (which passed 51 to 50), all amendments were not able to attain the fifty votes needed for Vice President Pence to break the tie vote.  With all Democrats and Independents firmly against repeal and replace, Majority Leader McConnell (R-KY) could not lose more than two of the 52 Republican votes.  In the end, Senators Collins (R-ME), Murkowski (R-AK) and McCain (R-AZ) prevented the bill from proceeding and the Majority Leader was forced to pull the bill from consideration at 1:40 a.m., Friday, July 28th.  The main reason cited by these senators was the expected impact of coverage losses in their states.  This is a major development considering the long-standing call to repeal the ACA, but the effort to reform American health care will no doubt continue given the fragile condition of the private insurance market and the ever-growing federal investment in the Medicare and Medicaid programs.From an O&P perspective, failure of a repeal and replace effort temporarily removes a threat to O&P access and coverage across the private insurance market and Medicaid expansion programs.  There may be additional legislative efforts later this year as well as efforts that do not require legislative action.  For instance, the Secretary of Health and Human Services has significant authority to redesign regulations that impact the essential benefit package and the category of benefits known as “rehabilitative and habilitative services and devices.”  NAAOP expects proposed regulations in the near future that will give states much more flexibility in designing essential benefits, and O&P benefits are likely to be among the benefits that are limited or restricted in certain ways.  NAAOP will continue monitoring this situation closely to ensure maximum coverage of O&P care for the benefit of patients and their providers.
  1. Recognition of Clinical Notes of the O&P Practitioner: On July 25th, the House of Representatives passed bipartisan Medicare legislation, H.R. 3178, to recognize that “documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by eligible professionals…”   This declaration will be tremendously useful in demonstrating medical necessity when Medicare contractors determine whether to deny O&P claims.  NAAOP recognizes and thanks AOPA for its extensive efforts on this achievement as well as the House sponsors including Glenn Thompson (R-PA), Mike Bishop (R-MI) and Mike Thompson (D-CA).  The bill now proceeds to the Senate where Senators Grassley (R-IA), and Warner (D-VA) have introduced the Medicare O&P Improvements Act, S. 1191, bipartisan legislation that includes this provision, as well as a number of other critical policy changes that benefit O&P.
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