Massive Medicare Orthotics Fraud Scheme Bolsters O&P Legislative Effort

Calling it “one of the largest health care fraud schemes in U.S. history,” the Department of Justice recently indicted 24 defendants and suspended Medicare payment privileges for 130 durable medical equipment companies for fraudulently billing $1.7 billion in Medicare orthotics.  The indictments included CEO’s and others associated with five telemedicine companies, including three licensed medical professionals.  The investigation involved over 80 search warrants in 17 federal districts, with tentacles reaching internationally into the Philippines and throughout Latin America.

The joint investigation involved the DOJ, the HHS Office of Inspector General, the FBI, CMS’s Center for Program Integrity, and the Internal Revenue Service.  The alleged scheme involved the payment of illegal kickbacks and brides by DME companies in exchange for the referral of Medicare beneficiaries by medical professionals working with fraudulent telemedicine companies for back, shoulder, wrist and knee braces that were medically unnecessary, according to the DOJ statement.  The defendants allegedly paid doctors to prescribe these orthoses either without any patient interaction or with only a brief telephonic conversation with patients they had never met, which were then shipped to the patient directly.

This type of announcement potentially tarnishes the reputation of the field, but NAAOP and its Alliance partners have been warning CMS, Congress, MedPAC and anyone else who would listen of these types of arrangements for months.  We continue to press CMS to move forward with implementing BIPA Section 427 to link Medicare payments for custom O&P care to accreditation and licensure status.

In addition, the new version of the Medicare O&P Improvement Act, which will likely be called the Medicare O&P Patient-Centered Care Act upon introduction in the 116th Congress, is likely to directly prohibit the drop shipment of orthoses and prostheses to beneficiaries, with certain limited exceptions.  This proposal to prohibit the shipment of orthoses and prostheses is expected to save the government money, which could be used to offset the cost of the proposal to restore Congressional intent by limiting the range of off-the-shelf orthotics subject to competitive bidding.

NAAOP will continue to work with AOPA, which is taking the lead on this legislation, as well as its Alliance partners, to advance this legislation and implement BIPA 427 for the benefit of O&P patients and the providers who serve them.

  • Written by NAAOP

Policy Forum Invitation

We invite you to join the NAAOP leadership in representing the O&P profession on Capitol Hill as we fight to ensure a patient’s right to choose their own provider and to maintain fair and reasonable reimbursement in a timely manner.

With one of the largest freshman classes in Congress, 2019 can prove to be a revolutionary year and advocacy has never been more imperative.  The Policy Forum is your best opportunity to learn the latest legislative and regulatory details and how they will affect you, your business and your patients. Once you are armed with the facts, we as a profession will educate our members of Congress to offer common sense solutions and share how the O&P profession restores lives and puts people back to work.

New to the Policy Forum? No worries, we have you covered with Lobbying 101, a pre-event civics refresher course that will also help you develop effective rhetoric when meeting with legislators. Your congressional appointments will be scheduled for you.

We hope to see you at this year’s Policy Forum May 7-8, and we invite you to bring a patient.  The Policy Forum host hotel will be the Ritz Carlton Pentagon City, 1250 South Hayes Street, Arlington, VA.

Register Online at http://bit.ly/19PFReg. We hope to see you at the Policy Forum.

Should you have any questions about the Policy Forum in general, please contact AOPA at (571) 431-0876 or info@aopanet.org.

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  • Written by NAAOP

NAAOP’s 2019 Fellows Announced & CMS OTS Orthotic Competitive Bidding

NAAOP Fellows:  NAAOP’s Board of Directors is pleased to announce the selection of NAAOP’s Policy Fellows for 2019.  The selection committee interviewed multiple, highly qualified nominees and chose two fellows, doubling the size of the NAAOP Fellowship program since last year’s pilot of the program.  The fellows are:

Alicia Carver: Alicia is a born advocate with an enthusiasm for advancing O&P care to benefit people with limb loss and limb difference.  Alicia is a graduate of Ohio University with a bachelor’s degree in technical and applied studies.  She has experience with state-based advocacy and brings the insight of individuals who experience the challenge of accessing prosthetic care in more rural areas of the country.  Alicia has personal experience with both custom orthotics and lower extremity prostheses. (Read Full Bio)

Susannah Engdahl: Susannah is a Ph.D. candidate in biomedical engineering from the University of Michigan, with a major focus on prosthetic and orthotic research.  Susannah will be very helpful in promoting the importance of evidence-based O&P practice, research, the O&P registry, and other important public policy issues impacting people requiring orthotics and prosthetics.  She has personal experience with upper extremity prostheses. (Read Full Bio)

These fellows will experience a 10-week policy fellowship this coming summer based in Washington, DC, with NAAOP serving as the principal host and sponsor of the program.  Many individual NAAOP board members, company members, and O&P organizations have contributed to the fellowship, both financially and by hosting the fellows for learning experiences during the fellowship itself.  NAAOP is incredibly grateful to all of its sponsors.

NAAOP President, Becky Hast, stated, “Finding Susannah and Alicia, both highly qualified and enthusiastic candidates, for the NAAOP Fellowship’s second year has reinforced our commitment to assisting this next generation of patient advocates to realize their potential. Many supporting associations, companies and individuals in the O&P community believe as we do — preparing for the future is some of the most important work we do today.”

OTS Orthotics:  CMS has announced that it will proceed with Medicare competitive bidding of Off-the-Shelf (OTS) orthotics over the next year and a half, culminating in implementation in the year 2021.  This is the first time CMS has expanded competitive bidding to O&P, albeit to a limited number of HCPCS codes.  23 knee and back orthoses will be impacted by the program.  Although OTS orthotics is the only type of O&P care authorized by law to be competitively bid, CMS interpreted the term “off-the-shelf” very broadly, impacting more than just orthoses that require minimal self-adjustment.  This risks losing the clinical care associated with these codes.

NAAOP is working with its O&P Alliance partners to address our concerns with CMS and is expected to soon introduce legislation to serve as an alternative to competitive bidding of OTS orthotics, among other O&P priorities.

  • Written by NAAOP

O&P Profession Prepares New Legislation to Protect Patients

As the 116th Congress gets off to a slow start, the President’s plans for health care policy will begin to emerge over the coming weeks.  First, the President will deliver his delayed State of the Union address which will include goals involving HIV/AIDS and perhaps other health care priorities.  Next, we will see the President’s FY 2020 federal budget proposals which will be released late due to the impact of the federal shutdown.  Once these proposals are made public, NAAOP will report on their potential impact on access to O&P care.

In the meantime, NAAOP is working with AOPA and members of the O&P Alliance on the path forward on off-the-shelf (OTS) orthotics and other priorities in the Medicare O&P Improvement Act.  Last year witnessed the enactment of the provision recognizing the value of the O&P practitioners’ clinical notes as part of the patient’s medical record for determining medical necessity.  This was a significant victory with many positive implications.

Extensive efforts were also expended to pass a provision redefining and limiting the scope of OTS orthotics subject to possible competitive bidding in the future, but this legislation did not make it across the finish line before the 115th Congress adjourned.  Late in the session, the Congressional Budget Office surprised everyone by claiming that the cost of the bill would have to be offset by a 35% reimbursement cut to over 50 orthotic codes, which was a non-starter.  The bill was actually pulled from House floor consideration hours before it was scheduled for a vote.

We are now in the process of working collectively to plot a legislative strategy for the 116th Congress.  We intend to reframe the O&P Medicare Improvement Act to focus on patient protection.  We intend to streamline the bill, focus on those provisions that developed traction in the previous Congress, and eliminate the most complex aspects of last year’s bill.  We are also discussing new provisions that will recast the bill in a manner that we hope will engender positive attention from Congress and the Administration.

This is particularly important now that CMS has announced its intention to subject 24 knee and back orthoses to competitive bidding in the next round of that program.  NAAOP and the O&P Alliance believes that 22 out of the 24 codes at issue are custom fit orthoses, not off-the-shelf, and are, therefore, pushing back hard against this proposal.

NAAOP will continue working with its O&P allies to advance policies that benefit patients and the providers who serve them.

  • Written by NAAOP