Major Medicare and VA Developments Impact O&P Care

As the Trump Administration continues to grapple with the rising number of COVID-19 cases across the nation, the Centers for Medicare and Medicaid Services (“CMS”) and the Veterans Health Administration (“VHA”) recently announced policy developments that impact the provision and reimbursement of orthotic and prosthetic care.

 

CMS Moves Forward with Prior Authorization for Six Lower Limb Prosthetic Codes

 

On July 1, 2020, CMS announced that it will require prior authorization for six lower limb prosthetic Healthcare Common Procedure Coding System (“HCPCS”) codes (L5856, L5857, L5858, L5973, L5980, and L5987) with dates of service on or after September 1, 2020, in four states—Texas, Pennsylvania, Michigan, and California.  CMS will then expand prior authorization nationwide beginning on December 1, 2020.  Prior to the COVID-19 public health emergency, CMS stated that the six lower limb prosthetic HCPCS codes would be subject to prior authorization as a Medicare condition of payment in these same four states beginning May 11, 2020, and nationwide beginning October 8, 2020.

 

In addition, on June 26, 2020, the Durable Medical Equipment Medicare Administrative Contractors (“DME MACs”) and the Pricing, Data Analysis, and Coding Contractor (“PDAC”) published a joint announcement and a revised Lower Limb Prostheses Local Coverage Article announcing that claims will not be paid for these six prosthetic codes with dates of service on or after January 1, 2021 unless the particular prosthetic component has undergone code verification by the PDAC and approval to bill a specific prosthetic L-code has been published on the appropriate Product Classification List.

 

NAAOP believes the circumstances that prompted CMS to delay prior authorization still exist and, in fact, have gotten worse.  NAAOP does not believe it is an appropriate time to impose new documentation requirements on health care providers and is taking steps to convey its position to CMS.

 

CMS to Resume Medicare Fee-for-Service Audits

 

On July 1, 2020, CMS also announced that medical review activities—including pre-payment audits conducted under the Targeted Probe and Educate program and post-payment audits—will resume beginning on August 3, 2020.  CMS previously suspended most Medicare Fee-for-Service medical reviews in light of the COVID-19 public health emergency.  CMS notes that providers selected for review should discuss with their DME MAC any COVID-19-related hardships they are experiencing that could affect audit response timeliness.

 

VHA Publishes Directive Regarding the Use of Not Otherwise Classified (“NOC”) Codes

 

On June 24, 2020, VHA released VHA Directive 1045 establishing the policy and responsibilities for developing and utilizing appropriate coding, market analyses, and contract guidance for prosthetic limbs and/or custom orthoses.  Among other things, VHA Directive 1045 confirms that the Department of Veterans Affairs (“VA”) may assign codes (i.e., miscellaneous “not otherwise classified” codes) to prosthetic limbs and custom orthoses, although the directive lacks details regarding the VA’s coding process.  NAAOP suspects that VHA published this directive in response to the Department of Veterans Affairs Office of Inspector General’s report entitled, “Veterans Health Administration: Use of Not Otherwise Classified Codes for Prosthetic Limb Components.”  A key conclusion of the directive is that the VA retains independent authority to code new technologies when CMS has not yet assigned—or does not intend to assign—a billing code.  This is a very positive development that NAAOP will pursue in the future.

 

NAAOP will continue to keep our members informed as regulatory developments continue.  Please consult our website for more information.

 

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NAAOP Works with O&P Alliance to Request Telehealth Coverage of O&P Care

In response to member requests, NAAOP has been working with the Orthotic and Prosthetic Alliance organizations over the past several weeks on a proposal for the Centers for Medicare and Medicaid Services (CMS) to authorize appropriately credentialed orthotists and prosthetists to submit claims for certain Medicare services furnished virtually (through telehealth) during the COVID-19 public health emergency.  This initiative culminated in an O&P Alliance letter submitted to the Secretary of Health and Human Services (HHS), Alex Azar, as well as the CMS Administrator, Seema Verma, on June 11, 2020.  A copy of the letter can be viewed here.

The letter states that in the case of senior and disabled Medicare beneficiaries who are at increased risk for COVID-19, “it is especially important that certified and/or licensed orthotists and prosthetists be able to assess, triage, and provide ongoing orthotic and prosthetic care to individuals who remain safely at home.  Under normal circumstances, patients would simply visit their orthotist or prosthetist when they were experiencing problems with fit, comfort, or function of an orthotic brace or prosthetic limb.  In a pandemic environment, the patient must weigh the prosthetic or orthotic problem against the risk of potential infection by visiting their orthotist or prosthetist in person.”

The letter makes the case that the COVID-19 pandemic has exposed an inequity in reimbursement of O&P clinical services that NAAOP and the Alliance believe should be rectified.  The letter cites a number of clinical examples of services that are not reimbursable to appropriately credentialed orthotists and prosthetists outside of the 90-day window after delivery of an orthosis or prosthesis, but are separately reimbursable to physicians and therapists under the CPT coding system.  Some of these clinical services include:

  • Reinforcing the appropriate wearing schedule;
  • Confirming the prosthesis or orthosis is being worn properly;
  • Evaluating the function of the device;
  • Assessing the need for any ancillary supplies;
  • Addressing fitting problems based on a change in the patient’s condition; and,
  • Observing any potential or actual skin breakdowns.

The COVID-19 pandemic has exposed this inequity and prompted NAAOP and the O&P Alliance to press forward with a request for CMS to authorize separate reimbursement of these clinical services through telehealth during the public health emergency.  Utilizing telehealth would allow these elements of care to be accomplished without placing orthotic and prosthetic practitioners or patients at unnecessary risk of contracting the COVID-19 virus.   

The letter recommends that CMS grant authority for appropriately credentialed practitioners to use either certain L codes or K codes to submit claims for these services, but is open to ongoing discussions with the agency to discuss alternatives in this regard.  NAAOP and the Alliance organizations will continue to work with CMS to advance this issue and will report back to our membership as developments occur.

  • Written by NAAOP

Update on COVID-19, Joint Statement on Race Relations, and O&P Policy Agenda

The National Association for the Advancement of Orthotics and Prosthetics (NAAOP) is proud to stand alongside our sister organizations in the O&P profession in signing and supporting this statement.

As a result of recent events in our country, we want all members of the O&P community to know that your O&P professional organizations stand together against racism. We are steadfast in our commitment to fairness, justice, and respect for all. We remain dedicated to open dialogue, active listening, and working toward enhancing diversity at all levels of our profession.

American Academy of Orthotists and Prosthetists (AAOP)
American Board for Certification in Orthotics, Prosthetics and Pedorthics (ABC)
American Orthotic and Prosthetic Association (AOPA)
Board of Certification/Accreditation (BOC)
National Association for the Advancement of Orthotics and Prosthetics (NAAOP)
National Commission on Orthotic and Prosthetic Education (NCOPE)

 

Update on COVID-19, Joint Statement on Race Relations, and O&P Policy Agenda

COVID-19:  NAAOP is pleased to welcome back our General Counsel, Peter Thomas, who, along with his parents and sister, acquired COVID-19 last month.  Peter is now healthy and back on the job to help the O&P community advance policies that benefit orthotists, prosthetists and the patients they serve.  Peter offers his sincere gratitude to all of those who reached out and offered their condolences and support to him upon the passing of his parents to COVID-19. His sister, Kathy, has also fully recovered. NAAOP also reiterates the importance of the O&P provider community remaining vigilant in protecting themselves, their staff, and their patients from COVID-19 transmission as the field begins accelerating the delivery of patient care.

Race Relations:  In the wake of the horrific events involving George Floyd and others, as well as the national protests that have ensued, NAAOP and its sister O&P organizations (AAOP, AOPA, ABC, BOC, and NCOPE) today issued a joint statement as follows:

 “NAAOP is proud to stand alongside our sister organizations in the O&P profession in signing and supporting this statement. As a result of recent events in our country, we want all members of the O&P community to know that your O&P professional organizations stand together against racism. We are steadfast in our commitment to fairness, justice, and respect for all. We remain dedicated to open dialogue, active listening, and working toward enhancing diversity at all levels of our profession.”

NAAOP recognizes it is not a “profile in courage” to state that we, as an organization, are opposed to racism, and in favor of fairness, justice, and respect for all.  Racial discrimination existed long before the recent events occurred but we feel strongly about being on record and hope that the widespread debate taking place across the country is a step forward in helping to resolve these intractable problems.

O&P Policy Update:  NAAOP is pleased that CMS suspended the pilot project on Medicare prior authorization of six prosthetic HCPCS billing codes in four states (i.e., CA, MI, PA and TX) originally scheduled to be implemented on May 11, 2020.  NAAOP advocated for this suspension because implementation of a new documentation system for certain prosthetic components during a pandemic created a major risk of delay and denial in access to patient care.

The Paycheck Protection Program (PPP) has been funded at over $600 billion to assist small businesses, including O&P practices, during the COVID-19 pandemic.  Many O&P practices have taken advantage of this program.  Recently, new legislation was enacted to modify the terms of the PPP such as extending the time period to expend the funds, the time period for paying back the loan (if it does not qualify as a forgivable loan), and increasing the share that businesses can expend on non-payroll expenses.  NAAOP encourages all O&P practices to examine this program to see whether it makes sense to apply.

Finally, NAAOP has been working with its O&P Alliance partners to explore ways for orthotists and prosthetists to be reimbursed for O&P telehealth services provided to O&P patients, outside of the 90-day window after delivery of an orthosis or prosthesis.  We will update NAAOP membership as this issue progresses.

  • Written by NAAOP

A Very Personal COVID-19 Update

As our country begins to reopen from the pandemic and O&P practices begin to return to some sense of normalcy, NAAOP encourages all O&P members and friends to redouble their efforts to take steps and implement procedures to minimize the spread of the COVID-19 virus. This virus is anything but contained, is highly virulent, and can have a devastating impact on those who acquire it. We reiterate the importance of protecting yourselves, your families, your staff, and your patients as you provide vital O&P services to patients in the future.

NAAOP’s General Counsel, Peter Thomas, lost his parents in the past two weeks to COVID-19 and now has the virus himself. Without the ability to mourn his parents in any traditional way, NAAOP is sharing a tribute he wrote to honor his parents and we invite you to read it to reflect on their exceptional lives. You can read the Bill and Anita Thomas tribute here. Thank you.

  • Written by NAAOP

O&P Practices Included in Stimulus Funding: Check Your Medicare Account Today

This morning (and throughout the day), the Centers for Medicare and Medicaid Services (CMS) directly deposited grants to ALL Medicare providers and suppliers, including O&P practices.  NAAOP encourages all O&P practice owners to check their Medicare accounts to ensure the funds were received.

The funds are part of the stimulus funding enacted under the COVID-19 legislation that passed two weeks ago today, known as the CARES Act.  The legislation created a $100 billion fund to assist health care providers to weather the pandemic.  The first $30 billion in stimulus funding is being distributed today.

These are grants and do not need to be paid back.  The amount of each O&P practice’s payment is determined automatically, based on the portion that the Medicare program paid each provider or supplier last calendar year.  Even as recently as last evening at 6:00 p.m., it was not clear whether O&P practices would be included in this initial round of stimulus payments. The fact that O&P practices were included should be welcome news to the O&P profession after another tough week.

Each recipient of funding must also agree to certain terms and conditions but these are fairly easy to meet.  These payments are separate and distinct from Medicare advance payments and any small business loans/forgivable loans for which O&P practices may have applied.

For a more detailed description of the program, please click here.

NAAOP will work in concert with its O&P Alliance partners over the coming days to submit suggestions to CMS as to how the agency should distribute the remaining $70 billion in funds, as they pertain to the O&P profession.  Among NAAOP’s priorities will be O&P practices located in COVID-19 hot spots throughout the country and O&P manufacturers and suppliers, who were not included in this first round of funding because they do not directly bill the Medicare program.

Please contact NAAOP if you have questions or comments related to these stimulus payments.  Thank you.

  • Written by NAAOP

COVID-19 Paycheck Protection Program Summary: Apply Today to Help Protect Your O&P Practice

As of Friday, April 3, 2020, the Small Business Administration (SBA) is accepting loan applications from lenders under the Paycheck Protection Program (PPP), enacted March 27th.  NAAOP strongly advises all O&P practices to explore this program to see if you are eligible and wish to participate in this first-come, first-served $349 billion program. Once these dollars are exhausted, the program will not accept additional applications. PPP loans do not have to be paid back if borrowers use at least 75% of the loan to retain employees and cover other specified expenses over an eight-week period. For more information on the PPP, please consult a detailed memo here, visit the SBA’s dedicated website here, and review the Interim Final Regulations, detailed guidance published April 2, 2020, here.

What is Available?

Under the PPP, small businesses and 501(c)(3) nonprofits may apply for loans of up to $10 million, based on a formula tied to the entity’s payroll costs. These loans may be applied to payroll costs between February 15 and June 30, 2020, including the costs of benefits (including healthcare and retirement), employee leave, insurance premiums, state and local taxes on employee compensation, mortgage interest, rent, and interest on outstanding debt. Loans may be forgiven in whole or in part if certain criteria are met, described below.

Who is Eligible?

Small businesses who are eligible for PPP loans generally must have fewer than 500 employees and must have been in operation as of February 15, 2020. This means that the vast majority of orthotic and prosthetic (O&P) practices across the country are eligible for these loans,

What Happens After I Apply?

Once an application is submitted and approved, the loan will carry an interest rate of 1.0% for a maximum term of 2 years. No personal guarantee or collateral will be required, and the borrower pays no fees. Loans do not have to begin to be repaid for six months, but interest accrues during that time. Loan funds used for payroll costs, mortgage interest payments, rent, and utility payments, up to the full amount of the loan (and interest) may be forgiven. At least 75% of the forgiven amount must be used for payroll costs. The loan forgiveness amount will be reduced if the borrower cuts their staff during the eight weeks after the origination date of the loan or reduces salaries or wages of any employee by more than 25%. The PPP was intended to keep workers employed, so borrowers are incentivized to do so via the loan forgiveness option.

How Do I Apply?

Applications may be submitted to any lending institution currently approved by the SBA or the Treasury Department, with additional lenders expected to join the program. The SBA has prepared a sample application form for participating entities, available SBA anticipates lenders can start processing applications beginning April 3, and the program will be open to applicants through June 30, 2020, but because of extraordinary demand, applicants are encouraged to apply immediately. It all starts by contacting your commercial lender. Additional resources provided by congressional offices on the PPP process can be found here and here.

  • Written by NAAOP

Medicare Accelerated and Advance Payment Program: What O&P Practices Need to Know During COVID-19

The Centers for Medicare and Medicaid Services (CMS) has announced a nationwide expansion of the Medicare Accelerated and Advance Payment Program (AAPP) to help providers and suppliers during the COVID-19 pandemic. Orthotic and Prosthetic (O&P) practices will be able to access expedited and advanced payments in order to fund their operations and increase cash flow during the crisis due to disruptions in claims submissions and processing. CMS’ fact sheet detailing eligibility and the application process can be found here.

What is Available?

Under the AAPP, O&P practices may essentially borrow against their expected future Medicare payments in order to maintain necessary financial resources during the COVID-19 crisis. O&P practices will be able to request advance payments up to 100% of their Medicare payments for a three-month period (between October and December 2019). Through the DME MACs, CMS will work to provide the requested payments within 7 calendar days of the application. Advance payments will be available throughout the public health emergency.

Who is Eligible?

With the expansion of the AAPP, providers participating in Medicare Part A and suppliers in Medicare Part B will be able to apply for and receive accelerated and advance payments. Specific eligibility criteria are outlined in the CMS fact sheet linked above, but current Medicare providers and suppliers in good standing (i.e., no delinquent payments owed to Medicare, not in bankruptcy, not currently under investigation) are eligible.

How Do I Apply?

CMS has published a step-by-step guide for applications in their AAPP fact sheet linked above. O&P practices should fill out a Request Form, which is provided by their individual region’s DME MAC. Forms are published on each MAC website and providers and suppliers can also contact their MAC’s COVID-19 hotline for assistance. To identify your region’s designated MAC, click here. The Request Form must be executed by an authorized representative, and suppliers/providers should state on the Request Form that they are experiencing cash flow problems due to COVID-19. Electronic submission is strongly encouraged, but mail or fax is accepted.

What Happens After I Apply?

Assuming your O&P practice meets eligibility criteria, the MACs should issue requested payments within 7 calendar days of the request. For 120 days after the payment is issued, O&P practices can continue their usual claims submission process and receive full Medicare payments. After that period, newly submitted claims will not be paid out, but will be automatically offset against the practice’s outstanding balance on the AAPP payment. After 210 days from the date the payment was issued, a MAC will send a repayment request for any remaining balance. After that the interest rate is relatively high; about 10% on an annual basis. Therefore, advanced payments equate to a 210-day no-interest loan.

NAAOP RECOMMENDATION

NAAOP recommends that all O&P practices explore taking advantage of this program. Whether you spend the advance payment or hold it in your account, this is a quick, no-cost way of helping to manage your practice’s cash flow during a very difficult time period. O&P practices should also consider applying for small business loans, which are forgivable if certain criteria are met. See NAAOP’s post on the Paycheck Protection Program.

  • Written by NAAOP

Special Alert: NAAOP Update: COVID-19 and Beyond

In these trying times, NAAOP provides this update of its activities in the wake of the COVID-19 pandemic.  Please consult the NAAOP website or contact us directly if you have questions or suggestions.  As this threat continues, we ask all NAAOP members and friends to adhere to state and local directives, practice social distancing, and stay as safe as possible.

  1. CARES Act Enacted and Small Business Relief: The third law addressing COVID-19 was enacted on Friday, March 27th.  The $2.2 trillion Coronavirus Aid, Relief, and Economic Security (CARES) Act contains massive employment and economic relief, in addition to resources to combat the virus.  The bill contains a $349 billion program intended to help small businesses and nonprofits weather the financial storm.  A summary of the health care provisions in the legislation is here and a summary of the small business loan program and other economic provisions is here.  We encourage all NAAOP members to explore this important program in order to maintain cash flow and retention of staff.
  2. Advance Medicare Payments Available: The Centers for Medicare & Medicaid Services (CMS) announced on Saturday, March 28 an expansion of its accelerated and advance payment program for Medicare-participating health care providers and suppliers, to ensure they have the resources needed during the COVID-19 national emergency.  Accelerated and advance Medicare payments provide emergency funding and address cash flow issues based on historical payments when there is disruption in claims submission and/or claims processing. The payments can be requested by hospitals; doctors; durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers; and others. Advance payments do not have to start being paid back for 120 days but must be repaid within 210 days.

To qualify for accelerated or advance payments, the provider or supplier must:

  • Have billed Medicare for claims within 180 days immediately prior to the date of signature on the provider’s/ supplier’s request form,
  • Not be in bankruptcy,
  • Not be under active medical review or program integrity investigation, and
  • Not have any outstanding delinquent Medicare overpayments.

Medicare will start accepting and processing the Accelerated/Advanced Payment Requests immediately. CMS anticipates that the payments will be issued within seven days of the provider’s request.  These are essentially no-interest loans that we hope O&P businesses will take advantage of to help maintain cash flow and their staff at this difficult time.  An informational fact sheet on the accelerated/advance payment process and how to submit a request can be found here: www.cms.gov/files/document/Accelerated-and-Advanced-Payments-Fact-Sheet.pdf

  1. NAAOP’s Statement on Orthotists and Prosthetists as Essential Providers: NAAOP issued a statement to all state Governors arguing that orthotists and prosthetists are essential health care providers that need to remain accessible to patients.  Based on member feedback, NAAOP reissued the statement to encourage all O&P practices to triage patients and provide care to those most in need while limiting exposure to the virus of patients and O&P personnel.  NAAOP believes O&P manufacturers and suppliers are critical to the timely delivery of patient care and should similarly be treated as essential.
  2. COVID-19 and Business Insurance: In an effort to serve as a resource to our members, NAAOP distributed an analysis prepared by the business insurance law firm, Miller Friel, examining ways that covered businesses could assert a claim for business losses due to COVID-19.  Most O&P practices are insured through Cailor Fleming and, unfortunately, these policies typically contain a virus exclusion, which makes coverage for COVID-19 losses unlikely.  O&P practice owners should examine their specific business insurance policy to confirm whether it contains a virus exclusion in the language and act accordingly.
  3. Request for Prior Authorization Delay: NAAOP has communicated our concern to CMS on the need to postpone implementation of prior authorization for six lower limb prosthetic codes beginning May 11th in four states: California, Texas, Michigan and Pennsylvania.  NAAOP believes this is no time to impose new documentation requirements on physicians, therapists, and others on the health care team that could have the effect of delaying (or even denying) patient care.  Health care providers should be focused on combating the virus, not on new documentation requirements.  NAAOP seeks a 6-month to one-year postponement of the prior authorization program.
  4. OTS Competitive Bidding: The financial impact of COVID-19 will have ripple effects across all business sectors for at least the next several quarters, and the O&P profession is no exception.  For this reason, NAAOP is considering asking CMS to delay competitive bidding of off-the-shelf orthotics, scheduled to begin on January 1, 2021, for at least one year.  NAAOP leadership seeks comments from its membership on this potential policy stance.
  5. NAAOP 2020 Fellowship Program: The NAAOP Fellowship Selection Committee and Board of Directors announced the 2020 summer fellows earlier this month.  Out of six highly qualified candidates, Nikki Grace-Strader and Lucas DeLuca were selected as the 2020 NAAOP Fellows:
    1. Nikki Grace-Strader: Nikki is a born advocate from Illinois and has an above-knee prosthesis through osseointegration.  Nikki’s compelling personal story and journey through health care and rehabilitation will serve her well as she advocates for O&P patient care in Washington, DC.
    2. Lucas DeLuca: Lucas has used an above-knee prosthesis since age 2.  He has a wide variety of experiences that will serve him well as an NAAOP fellow, including a Master’s degree in Disability Studies.  Currently based in California, Lucas hopes to move to Washington, DC permanently to focus full-time on policy and advocacy.

2020 NAAOP Fellowship Postponed:  Unfortunately, due to the risks and uncertainties created by the COVID-19 pandemic, NAAOP was forced to postpone the Fellowship program until the summer of 2021.  If available at that time, these same two fellows will remain in the program and are enthusiastic about participating at that time.

NAAOP will continue to keep our members and friends informed as developments on COVID-19 continue.  Please consult our website at www.naaop.org for more information.

  • Written by NAAOP

NAAOP 2020 Fellowship Program

The NAAOP Fellowship Selection Committee and Board of Directors announced the 2020 summer fellows earlier this month. Out of six highly qualified candidates, Nikki Grace-Strader and Lucas DeLuca were selected as the 2020 NAAOP Fellows.

Nikki Grace-Strader

Nikki is a born advocate from Illinois and has an above-knee prostheses through osseointegration. Nikki’s compelling personal story and journey through health care and rehabilitation will serve her well as she advocates for O&P patient care in Washington, DC.

Read more about Nikki

Lucas DeLuca

Lucas has used an above-knee prosthesis since age 2. He has a wide variety of experiences that will serve him well as an NAAOP fellow, including a Masters degree in Disability Studies. Currently based in California, Lucas hopes to move to Washington, DC permanently to focus full-time on policy and advocacy.

Read more about Lucas

2020 NAAOP Fellowship Postponed

Unfortunately, due to the risks and uncertainties created by the COVID pandemic, NAAOP was forced to postpone the Fellowship program until the summer of 2021. If available at that time, these same two fellows will remain in the program and are enthusiastic about participating at that time.

  • Written by NAAOP