Special Alert: Major Developments in O&P Policy

Over the past two weeks, a number of major, long-awaited developments in O&P policy have occurred. NAAOP and its Alliance partners have been diligently working on these measures over the past few years and we are excited to share an update on the progress that has been made.

  • Issuance of CMS Interagency Workgroup’s Consensus Document: After publishing a DME MACs Draft Local Coverage Determination (LCD) for Lower Limb Prostheses in 2015 that caused enormous public comment and concern, CMS placed that document on hold and formed an Interagency Workgroup in February 2016 to further explore the issues. Last week, CMS published the results of the Workgroup’s efforts. The Workgroup has recommended CMS to take the following immediate actions:
  • Instruct the DME MACs to remove the 2015 Draft LCD and continue coverage for lower limb prostheses under the current LCD, with no changes.
  • Support the establishment of an interagency federal research group in order to create a guidance document to promote industry research standards in the field of lower limb prostheses.
  • Consider creating a National Coverage Determination (NCD) to evaluate the use of microprocessor knees (MPK) for individuals using their prostheses as a limited community ambulator (K2 functional level).

The removal of the draft LCD is a major victory for the O&P community. However, there are still significant areas of concern in the Consensus Document that could be improved. These include:

  • The recommendation that CMS move toward pre-authorization of lower limb prostheses, a process led by the DME MACs.
  • The characterization of prosthetists as “consultants” to the physician for purposes of determining functional level.
  • The conclusion that current literature does not support improved functional health outcomes of power assist ankles and vacuum systems. Nonetheless, these devices may be covered if justified in the pre-authorization request.

Note: On June 21st, the DME MACs announced the retirement of the Draft LCD on Lower Limb Prostheses. This Draft LCD is finally dead.

  • Release of the MEDPAC Report on Orthotics: The Medicare Payment Advisory Commission (MEDPAC) report, filed with Congress last week, includes a substantial section on orthotics and recommends implementation of competitive bidding for off the shelf (OTS) orthotics. However, the report largely focused on abuses of this benefit by non-orthotist providers and even suggested that orthotists, like physicians, should be able to provide OTS orthotics without having a Medicare competitive bidding contract. Importantly, the report did not recommend expansion of competitive bidding to all orthotics and prosthetics, a policy that had been considered prior to NAAOP and its Alliance partners meeting with MEDPAC staff.
  • VA Report by OIG: Over the next few weeks, we expect to see a report from the Office of Inspector General (OIG) of the Department of Veterans Affairs (VA) that may impact coding and coverage of orthotics and prosthetics. We will share this with you when we learn more.
  • Written by NAAOP

Inaugural Fellow Nicole Ver Kuilen

June 4, 2018

Dear NAAOP members:

It has been said that education is the greatest gift we can give to the next generation, a gift so powerful that it has the potential to change the world. I’m on my fourth day shadowing Peter Thomas as NAAOP’s inaugural health policy and advocacy fellow, and I have already witnessed the fruits this fellowship will bring for me and, hopefully, other fellows for years to come.

For 31 years, NAAOP and its committed membership have advocated on behalf of the O&P community, unifying our advocacy and policy efforts to benefit patients like me, who at 10 years old did not have a voice in my care. Now, the charge is ready to be handed to the next generation. This fellowship is a critical part in bridging that hand-off, developing future leaders in the O&P field. I’m excited, and honored, to be part of this endeavor.

Thanks to many of you, I will have some transformational experiences packed into 10 short weeks in NAAOP’s national office in Washington, D.C., as well as the opportunity to travel to:

  • Stokosa Prosthetic Clinic, American Prosthetic Institute, Karoub Associates, and Michigan O&P Association in Okemos, MI, hosted by NAAOP board member and past president, Jan Stokosa, with a special kick-off celebration at his home.
  • Children’s Hospital of Atlanta (CHOA) O&P program in Atlanta, GA through the generous support of ABC, with extensive help from Cathy Carter and Steve Fletcher.
  • Hanger Clinic’s headquarters in Austin, TX, hosted by NAAOP board member Maggie Baumer, where I will be exposed to leading research, outcomes measurement, patient experience, compliance, and the peer visitor program.
  • OPGA in Cedar Falls, IA, hosted by NAAOP board member Todd Eagen.
  • Amputee Coalition’s National Conference in Tucson, AZ, where I will have the opportunity to attend and speak on a panel, hosted by the Amputee Coalition and President Jack Richmond.

Throughout the summer, I will also have the special opportunity to meet the staff and learn the organizational history of the O&P Alliance, including site visits to BOC, ABC, AOPA, and AAOP, as well as NCOPE. Thanks to Ted Kennedy, Jr., I will also have the opportunity to network with other disability interns and learn about the history of the disability rights movement through the American Association of People with Disabilities’ (AAPD) Summer Internship Program. I will also be exposed to countless visits to Capitol Hill, congressional hearings, coalition and think tank meetings, as well as learning state-based and federal public policy.

This line-up is truly incredible. To have such an extensive fellowship program developed in its first year is a testament to the dedication and vision of NAAOP. And it would not be possible without the generous financial commitments from Jan Stokosa, CP, Stokosa Clinic; Todd Eagen, OPGA; Vinit Asar, Hanger; Michael Rayer, Prosthetic Innovations; Claudia Zacharias with BOC; and the very first contributor to the NAAOP fellowship, Dena and George Breece.

I am incredibly grateful to carry the torch as the first NAAOP fellow, to lay a strong foundation for this program. The impact of this fellowship will only continue to multiply for the field, if we choose to invest in the leaders of tomorrow. Thank you for investing in me, and this fellowship for years to come.

In gratitude,
Nicole Ver Kuilen

  • Written by NAAOP

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.

  • Written by NAAOP

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
georgebreece@naaop.org or 910 583 2161

  • Written by NAAOP

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 www.naaop.org.

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……

  • Written by NAAOP

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.

  • Written by NAAOP

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 www.naaop.org 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)

  • Written by NAAOP

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.
  • Written by NAAOP

Contact your Senators/Representatives Today to Support the Medicare O&P Improvement Act

The House and Senate are seriously considering inclusion of key provisions of the Medicare O&P Improvement Act (S. 1191 and H.R. 2599) in the Medicare “extenders” legislation expected to be considered in the coming weeks.  The Medicare O&P Improvement Act is bipartisan legislation introduced by Senators Grassley (R-IA) and Warner (D-VA) and Congressmen Glenn Thompson (R-PA) and Mike Thompson (D-CA).  It is designed to improve the quality of patient care and treatment outcomes while limiting waste, fraud and abuse in the Medicare orthotic and prosthetic benefit.  There are a number of critical provisions in the act that should be included in the Medicare “extenders” legislation and passed immediately.

Recognition of Clinical Notes:  The House already has passed one of the provisions in the bill (Section 5) as part of the Medicare Part B Improvement Act (H.R. 3178, Section 103).  This provision would clarify that the clinical notes of the prosthetist or orthotist are considered part of the patient’s medical record, and will help establish the medical necessity of prostheses and orthoses provided to Medicare beneficiaries.

Linking O&P Provider Qualifications with Medicare Billing Privileges:  Section 8 of the Medicare O&P Improvement Act directs CMS to issue regulations on a section of the federal law that was enacted in 2000 but never implemented (BIPA Section 427).  Congress should enact this provision to require CMS to implement this federal law governing the qualifications necessary to provide custom-fabricated orthotics and prosthetics to Medicare beneficiaries.

Clarifying the Scope of Off-the-Shelf Orthotics: Congress exempted custom O&P care from DME competitive bidding in the Medicare Modernization Act of 2003 but permitted competitive bidding for “off-the-shelf” orthotics, defined in the statute as orthoses requiring “minimal self-adjustment.”  CMS subsequently issued regulations that dramatically expanded the scope of off-the-shelf orthotics, contrary to congressional intent.  Section 7 of the Medicare O&P Improvement Act would restore the original definition, protecting patients who require orthotic treatment by ensuring they receive the clinical services needed for orthoses to fit and function properly.

HOW TO HELP:  Go to www.naaop.org and access the Legislative Action Center.

  1. Use the template letter and amend it as you deem appropriate. Send three messages, one to your Congressman, and one to each of your Senators.
  2. Make three phone calls: Call your Congressman (202-225-3121) and follow the prompts to reach your representative.  Then call the Senate (202-224-3121) and ask to speak with each of your two Senators.
  3. MESSAGE:  Please actively support inclusion of the Medicare O&P Improvement Act in the Medicare “Extenders” Legislation currently pending in Congress.
  • Written by NAAOP

Veterans Choice of O&P Practitioner

Submit Comments by December 15th to Help Preserve Veterans’ Right to Choose

NAAOP asks its members and friends to take action by December 15th by submitting comments opposing the proposed Veterans Administration regulation to eliminate amputee veterans’ choice in selecting a VA prosthetist/orthotist or a private, VA-contracted prosthetist/orthotist, to provide their O&P care.  As currently drafted, the VA’s proposed rule found at this link (https://www.federalregister.gov/documents/2017/10/16/2017-22358/prosthetic-and-rehabilitative-items-and-services) could seriously erode veterans’ access to appropriate, timely and convenient O&P care.

For over fifty years, the VA has contracted with private practitioners to provide timely and quality O&P care to veterans with limb loss and other disabilities who honorably served our country.  These contractual arrangements offer veterans with amputations greater access to high-quality professionals, the newest technologies, and state-of-the-art laboratories where prostheses and orthoses are designed, fit and fabricated.  For years, private, VA-authorized O&P practitioners have played a vital role in augmenting the VA’s capacity to serve our nation’s veteran amputees and others with disabling conditions.

On October 16, 2017, the VA issued a proposed rule that would reverse this long-standing VA practice by insisting that the VA has the sole authority to determine whether a veteran can access a private O&P practitioner with a VA contract.  The proposed rule states that this is an “administrative business decision” without any reference to the importance of clinical circumstances of the patient.

This proposal would effectively deny veterans their right to select a prosthetist/orthotist of their choice, an important quality indicator and patient protection that has long been VA policy.  This proposal is striking because it runs counter to the key tenets of the Veterans CHOICE Program, which allows veterans to access VA-funded health care services in the private sector.

ACTION ALERT:  Please take action by December 15th by submitting comments to the VA opposing this proposed change in policy and asking the VA to maintain veterans’ right to choose their O&P practitioner, whether that practitioner is a VA employee or a private O&P practitioner with a VA contract.  Here is how you can help and thank you for your efforts:

  1. Click here to access a draft letter for practitioners to use in submitting comments.
  2. Click here to access a draft letter for your veteran patients to use in submitting comments.
  3. Modify the letter(s) to suit your own situation and add any additional comments you wish. Ask your veteran patients to participate.
  4. Go to this link, https://www.regulations.gov/comment?D=VA-2017-VHA-0023-0003 to electronically submit your comments. You have two options:
    1. Write “See attached letter” in the comment window and follow directions to upload your letter in PDF format; or,
    2. Copy and paste the contents of your letter into the comment window and hit send.
  • Written by NAAOP