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

ATTENTION O&P PRACTICE OWNERS, MANUFACTURERS AND SUPPLIERS

BUSINESS INSURANCE ALERT ON COVID-19: Immediate 3-Step Insurance Strategy for Coronavirus Losses

As part of NAAOP’s ongoing effort to help inform our O&P members and friends on efforts to combat the COVID-19 virus, we have partnered with Miller, Friel, a business insurance law firm in Washington, DC, to help assist the O&P profession.  We pass along this important alert which offers O&P practices, manufacturers, and suppliers a step-by-step approach to filing a business insurance claim for COVID-19 losses.

Please take the time to read the article linked below and follow the three steps outlined by my friend and colleague, Brian Friel.  His law firm, Miller Friel, has agreed to co-host with NAAOP a webinar in the near future to answer O&P provider questions about filing business insurance claims for COVID-19 losses. More details will follow.  Thank you.

Peter Thomas
General Counsel, NAAOP


Dear Valued Client,

We wanted to send you a quick note to let you know what we have been doing for our clients with respect to Insurance Recovery of Coronavirus Losses.  We are advising our clients to follow a three step strategy using a red light/green light approach:

  1. Review relevant policies.  For most businesses this will include Property and Business Income policies (Property/BI policies).  If also purchased, pollution-specific policies (PLL) are also relevant.
  2. Review and characterize policies as either red light or green light policies.  Red light policies are those that contain a bacteria/virus or communicable disease exclusion.  Green light policies are all others.
  3. Immediately provide notice of claims to insurers for all green light policies.  Most Property/BI policies require notice “as soon as practicable” from date of loss.  The clock on this has already started, so action is required.

There is a lot of misinformation out there concerning coverage for coronavirus claims, particularly from insurance companies.  We hope that this 3-step strategy helps, and we stand ready to assist you in this time of crisis.  We look forward to hearing from you.  In the meantime, please be safe.

Best regards,
Brian G. Friel
Miller Friel, PLLC

  • Written by NAAOP

NAAOP COVID-19 Statement on Essential-Urgent Prosthetic-Orthotic Services

Yesterday, NAAOP issued the following alert to all state Governors, COVID-19 State Task Forces, and Health Insurance Commissioners. The alert makes clear that during the COVID-19 national emergency, state and local health authorities should consider orthotic and prosthetic practices as essential providers that must remain accessible to patients in need of orthotic and prosthetic care during this pandemic. NAAOP is taking this step in response to a number of O&P practitioners in states that are contemplating shutting down “non-essential” health care providers.

Based on member feedback, NAAOP today issued this revised statement clarifying that prosthetic and orthotic practitioners should triage patients to treat those with the most urgent needs and postpone non-urgent care in the interests of patient and practitioner safety.

Please feel free to distribute this statement to anyone you think should see it.


March 20, 2020

VIA ELECTRONIC DELIVERY

 

ATTENTION:
ALL STATE GOVERNORS

COVID-19 STATE TASK FORCES
HEALTH INSURANCE COMMISSIONERS

RE: Prosthetic and Orthotic Care is an Essential Health Benefit that Patients Must Have Access to During the Response to the COVID-19 Pandemic

Americans in urgent need of prosthetic limbs and orthotic braces must be permitted to access orthotic and prosthetic care during the COVID-19 pandemic.  These services are essential health benefits as defined by the Patient Protection and Affordable Care Act (ACA)[1] and should be treated by the federal, state and local governments as necessary health care services, providers of which should remain accessible to provide orthotic and prosthetic (O&P) care to patients in need.  To reduce the risk of infection, federal, state and local governments should issue further guidance and safety protocols to minimize transmission of the virus during patient care encounters.  O&P practitioners should triage patients to serve those most in need and seek to postpone non-urgent treatments until the threat decreases.

On March 18, 2020, the White House Task Force on COVID-19, in conjunction with the Centers for Medicare and Medicaid Services (CMS), issued recommendations on adult elective surgery and non-essential procedures.  The recommendations stated that all adult elective surgeries as well as non-essential medical, surgical, and dental procedures should be delayed during the COVID-19 outbreak.  The guidance stipulated that such decisions remain the responsibility of local healthcare delivery systems, including state and local health officials.

The guidance also stated that when making these decisions, state and local authorities should consider not only the clinical situation but resource conservation of personal protective equipment, hospital beds, and availability of ventilators.  (The provision of prosthetic and orthotic care does not impact the availability of hospital beds or ventilators.)

The National Association for the Advancement of Orthotics and Prosthetics (NAAOP), a national organization focused on the advancement of prosthetic and orthotic care, stands ready to assist the federal, state and local governments as they implement measures to minimize the risk of COVID-19 infection, but potentially eliminating all access to prosthetic and orthotic professionals as non-essential would not be prudent and would result in many patients having their urgent prosthetic and orthotic needs go unmet.

The White House/CMS recommendation defines as Tier 3b surgical services that should not be postponed, including surgeries due to trauma as well as limb threatening vascular surgery.  These are medical procedures that require immediate post-operative (and in some cases, pre-operative) prosthetic and/or orthotic care in order to achieve appropriate patient outcomes.  Other examples of the need for continued access to prosthetic and orthotic professional services include:

  • Infants and toddlers with Plagiocephaly in need of cranial orthotic “helmets;”
  • Children with severe scoliosis, cerebral palsy or other congenital disabilities that require orthotic bracing or prosthetic limb care;
  • Survivors of limb loss due to vascular disease and trauma but also other reasons such as cancer and other diagnoses;
  • Orthotic treatment to assist in treating low back pain, spinal fractures, joint disease, and other conditions that affect the ability to walk and remain functional without significant pain; and,
  • Limb loss as a result of complications from diabetes.

In these and other urgent situations, the timeliness of prosthetic and orthotic care, as part of the rehabilitation plan of care, is instrumental to patients in achieving positive functional outcomes without unnecessary complications.  We strongly urge the federal, state and local governments to continue to permit access to essential prosthetic and orthotic clinical care during the response to the COVID-19 outbreak and welcome the opportunity to work with state and local decision-makers to develop more specific guidance to keep patients and providers safe during O&P treatment. We also encourage O&P practitioners to triage patients to serve those most in need and postpone treatments that can be safely postponed until the threat of infection is reduced.  We look forward to working with state leaders as the trajectory of this pandemic evolves and seek to maximize patient safety in this process.

Thank you for your consideration of this recommendation and please contact Peter W. Thomas, NAAOP General Counsel, at Peter.Thomas@powerslaw.com or 202-607-5780 if you have any questions.

Sincerely,
Glenn Crumpton, LPO
NAAOP President


[1] Section 1302 of the ACA (42 U.S.C. 18001) defines ten essential health benefits, including “rehabilitative and habilitative services and devices.”  This benefit category clearly includes coverage of prosthetic and orthotic care as defined by the Summary of Benefits and Coverage, and consistent with both the Institute of Medicine report on Essential Health Benefits and Congressional intent expressed during passage of the ACA itself. See IOM (Institute of Medicine). 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press; See 111 Cong. Rec. H1882 (daily ed. Mar. 21, 2010) (statement of Rep. George Miller).
  • Written by NAAOP

CMS Expands Prior Authorization to Six Lower Limb Prosthetic Codes

On February 11, 2020, the Centers for Medicare and Medicaid Services (“CMS”) announced that six lower limb prosthetic Healthcare Common Procedure Coding System (HCPCS) codes will be subject to prior authorization as a Medicare condition of payment.  The six HCPCS codes (L5856, L5857, L5858, L5973, L5980, L5987) describe additions to three microprocessor-controlled prosthetic knees, a microprocessor-controlled ankle-foot prosthesis, and two prosthetic feet.  CMS officials stated that they do not plan any time soon to expand prior authorization to other O&P codes.

CMS will initially implement prior authorization for these codes in only four states—Texas, Pennsylvania, Michigan, and California—effective May 11, 2020.  CMS will then expand prior authorization nationwide beginning on October 8, 2020.  Once this requirement goes into effect, all claims associated with the six identified HCPCS codes that do not have provisionally affirmed prior authorization will be denied payment.  CMS intends to issue additional guidance regarding its deadlines to respond to prior authorization requests for the aforementioned prosthetic codes.

NAAOP has previously expressed concerns regarding the application of prior authorization to orthoses and prostheses.  O&P fabrication and fitting is a detailed, time- and labor-intensive undertaking that is critical to maximizing the beneficiary’s future function.  Unlike durable medical equipment, which is largely commodity-based, prosthetic care is clinical in nature and service-oriented.  Prior authorization has the potential to interfere with the provision of timely and appropriate care.  Any delay in the prior authorization process will directly result in further delays of treatment, and may led to denials of care.

However, prior authorization appears to remain a priority for the Trump Administration.  On February 10, 2020, President Trump released his fiscal year 2021 budget, which contained a proposal to expand prior authorization “to all Medicare Fee-for-Service items and services.”  Under the President’s proposal, CMS would target “items and services that are at high risk for fraud and abuse, such as inpatient rehabilitation facilities.”  At this time, CMS has not formally proposed a regulation that would implement this budget proposal expanding prior authorization, so it is not yet effective.

In fact, one day after the publication of the President’s Fiscal Year 2021 Budget, CMS Administrator Seema Verma seemingly contradicted the President’s proposal, noting that “[p]rior authorization requirements are a primary driver of physician burnout, and even more importantly, patients are experiencing needless delays in care that are negatively impacting the quality of care they receive.”  She stated that prior authorization has been indefensible for years and that she planned to reform or restrict prior authorization this year.  The inconsistent message strikes a discordant tone as CMS implements prior authorization of these six prosthetic codes.

NAAOP will continue to monitor the implementation of prior authorization to the affected prosthetic codes and update our members and friends as developments occur.

  • Written by NAAOP

O&P Advocacy in 2020: A Look Ahead

Happy New Year to all of NAAOP’s members and friends! As we begin the second session of the 116th Congress, a very busy agenda is expected in the coming months.

NAAOP Fellowship Applications Due January 31st
The third year of NAAOP’s Health Policy and Advocacy Fellowship is about to0 begin. Fellowship applications are due January 31, 2020. Two fellows who use custom orthotics or prosthetics will be selected to spend 10 weeks in Washington, DC this summer learning about O&P policy and advocacy in the broader context of health care and disability policy. We encourage all NAAOP members and friends to think of someone who might be interested and a good candidate and expose them to this opportunity. For more information and the application, please go to www.naaop.org.

O&P Leadership Conference
AOPA is hosting its annual O&P leadership conference for the weekend of January 10th. The Leadership Conference is a great way to kick off the year and activate the O&P community. With pending legislation in Congress, this will be a great opportunity to learn more about the Medicare Orthotics and Prosthetics Patient-Centered Care Act and how you can help pass the bill.

Medicare O&P Patient-Centered Care Act
Congress is working on lowering the cost of prescription drugs and reducing the impact of surprise medical bills. In addition, Congress extended certain Medicare payment provisions until May 22nd when these programs will expire unless they are reauthorized. This means that a Medicare bill is likely to be passed by this date, or at some point shortly thereafter. The O&P community has an opportunity to work hard to try to attach the O&P Patient-Centered Care Act to this legislation. If this is not possible, we also have an opportunity to perhaps have it included in a second version of the 21st Century Cures Act, informally known as “Cures 2.0.” This bill offers the O&P community another chance of getting the Patient-Centered Care Act included in a moving legislative vehicle, but only if we all come together and build strong support for passage of the legislation.

Veteran Choice of Practitioner
NAAOP, AOPA and the O&P Alliance worked together over the past several months to clarify that veterans continue to have a choice of their practitioner, whether that practitioner is a VA employee or is a sanctioned VA provider with a contract with the VA to provide O&P services to veterans. The Omnibus Spending bill for FY 2020 included some language on this issue but the direction to the VA was not as strong as it could have been. NAAOP will continue to work on this important issue in concert with AOPA and other Alliance organizations.

  • Written by NAAOP