Congress Returns as MedPAC Discusses Expansion of DMEPOS Competitive Bidding

The U.S. House and Senate return to Washington this month to debate and pass a large number of appropriations bills that will fund the federal government for Fiscal Year 2020, which begins on October 1st.  In all likelihood, now that a budget agreement was reached in July, the bills will begin to move through Congress and be signed by the President, but it is likely a short-term continuing resolution will be necessary to allow them to finish this massive job.

In the meantime, CMS is accepting comments until September 27th on a proposed rule on Durable Medical Equipment, Prosthetics, Orthotics, and Supplies that changes how CMS sets reimbursement levels for new technologies and dramatically expands prior authorization of prosthetics and orthotics.  The full text of the rule, which also includes updates to CMS’ payment system for end-stage renal disease, can be found here, and a CMS fact sheet summarizing the major provisions in the rule can be found here.

Finally, on September 5th, 2019, the Medicare Payment Advisory Commission (MedPAC), an independent legislative branch agency that provides Congress with analysis and policy advice on the Medicare program, held a meeting that included a session titled Examining Competitive Bidding for Diabetes Testing Supplies and Expanding Medicare’s DMEPOS Competitive Bidding Program. A slide deck used to make the presentation can be found here.

The presentation provided an overview of the competitive bidding program (CBP) implemented under the Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) payment system, with a particular focus on the impact that CBP has had on spending and utilization for diabetes testing supplies. The presentation set the stage for a discussion of ways to expand the DMEPOS CBP throughout the Medicare program. The Commissioners offered questions and feedback on the presentation and the future of Medicare competitive bidding.

 MedPAC staff provided an overview of the two payment systems for DMEPOS items, the competitive bidding program and the fee schedule. Staff contended that many DMEPOS fee schedule amounts are “excessive,” and that the implementation of competitive bidding has resulted in “substantially” lower payment rates: among the 25 highest-expenditure products in 2017.  In fact, median payment rates declined nearly 50%.  Though MedPAC admits that utilization decreased for most product categories included in CBP, the Commission contends that CBP did not disrupt patient access, citing CMS data that shows no negative changes in beneficiary outcomes.  To further support the competitive bidding program, staff cited data demonstrating increased spending on non-CBP products.

The presentation also discussed the April 2019 Department of Justice enforcement action alleging a nationwide fraud scheme for off-the-shelf (OTS) orthotics, and posited that excessive fee schedule rates for these items likely encouraged the alleged abuse. Staff concluded the presentation by suggesting that the Commissioners and policymakers consider expanding CMS’s authority to include additional products in the CBP, specifically pointing to a list of candidate products identified by MedPAC in 2017.  NAAOP will continue to closely monitor competitive bidding and report to our membership as developments occur.

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Fellows Report Progress and Say Farewell While CMS Drops Alarming DMEPOS Proposed Regulation

The 2019 NAAOP Fellows, Alicia Carver and Susannah Engdahl, finished their fellowship last week and report learning a great deal about O&P policy and advocacy throughout the course of the summer.  NAAOP extends sincere thanks to the Alliance organizations for hosting the fellows, as well as numerous contributors and hosts across the country who exposed them to all aspects of orthotics and prosthetics.

Alicia Carver:  Alicia’s principal project this summer involved direct federal advocacy on the soon-to-be-introduced Medicare O&P Patient-Centered Care Act.  Alicia and Susannah joined forces to visit over 35 House and Senate offices to promote the policies in the bill and to seek cosponsors of the legislation.  The meetings focused on the three major committees of jurisdiction over the bill, the House Ways & Means Committee, the House Energy & Commerce Committee, and the Senate Finance Committee.  In fact, the fellows’ last meeting was conducted alongside OPGA’s lobbying team with the chief health staffer of Senate Finance Committee Chairman Charles Grassley (R-IA).  All of the hill meetings were coordinated with the O&P Alliance and with AOPA’s efforts in spearheading the bill.

Susannah Engdahl:  Susannah’s principal project this summer involved the development of a compilation of clinical and economic evidence from academic literature to demonstrate the value of O&P care for use in advocacy materials.  Citations to the evidence base are critical in making compelling policy arguments and Susannah’s work product this summer will inform NAAOP’s policy and advocacy efforts well into the future.

CMS Issues DMEPOS Proposed Rule

On July 29, 2019, the Centers for Medicare and Medicaid Services (CMS) released the proposed rule containing updates to the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) regulations. The full text of the rule can be found here, and a CMS fact sheet summarizing the major provisions in the rule can be found here. Comments on the proposed rule are due September 27, 2019 and can be submitted electronically by following this link or visiting www.regulations.gov and searching “CMS-1713-P.”

The rule includes a number of provisions that impact orthotics and prosthetics (O&P).  Unfortunately, the rule again applies DME-centric policies to O&P care, thereby increasing the importance of our legislative push to further separate DME from O&P.  The most significant proposals involve a new process for calculating payment amounts for new technologies receiving HCPCS codes (“gap-filling”) which may create a major disincentive for innovators to invest in bringing new O&P technologies to market.  The proposed rule also includes a new consolidated list of DMEPOS eligible for prior authorization.  In addition to the 82 L-codes already eligible for prior authorization, CMS adds 144 new L-codes to the Master List, with little justification.  NAAOP will be working with its Alliance partners to respond forcefully to this proposed rule.

Thank you again for your support of NAAOP and our Fellowship Program.  And thank you to Alicia and Susannah for bringing their skills, enthusiasm, dedication, and personal knowledge of O&P care to Washington, DC.

  • Written by NAAOP

NAAOP Fellows visit OPGA, NCOPE, ABC, and AOPA

OPGA, NCOPE, ABC, and AOPA

By Alicia Carver and Susannah Engdahl

The NAAOP Fellows were on the road again during the week of June 24th. We started with a visit to Iowa, where we met with Todd Eagen, President of OPGA, and Kelly Turner, Member Development Coordinator of OPGA. They taught us how OPGA works to support independent O&P practitioners by providing services relating to insurance, business management and marketing, and by offering access to discounted supplies from manufacturers. We also had a meeting where we learned about advocacy from several Iowa state legislators, including former Iowa State Senator Jeff Danielson, former Iowa House Speaker Christopher Rants, and Iowa State Representative Timi Brown-Powers. It was very helpful to hear their perspectives on how to advocate in a manner that legislators find helpful.

Our next trip was to Virginia, where we were hosted by NCOPE and ABC. Robin Seabrook, Executive Director of NCOPE, shared a presentation about the history of NCOPE and the role that it currently plays in accrediting orthotics and prosthetics education programs, as well as elevating the educational standards for practitioners in training. Afterwards, we learned about ABC from Cathy Carter, Executive Director, and Steve Fletcher, Director of Clinical Resources. They talked with us about the process that must be followed for certifying practitioners and accrediting orthotics and prosthetics facilities, as well as the role that ABC plays in overseeing these processes. We also appreciated learning about the missions of NCOPE and ABC complement each other and ultimately work together to advocate for high quality patient care and professional standards.

We ended our week with AOPA. There we met with Eve Lee, Executive Director of AOPA, and Ashlie White, Director of Strategic Alliances. We sat in on a conference with the whole AOPA team, gained a more in depth knowledge about AOPA and learned how they as a collective team help the orthotic and prosthetic profession. We learned how to utilize the AOPA Co-OP database. It is a wonderful and valuable tool that can help us through our fellowship and beyond as we find our place in the world of advocacy and health policy.

We had a great time during all of our trips and would like to thank everyone who shared their time with us! We felt very welcomed by everyone who hosted us.

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NAAOP Fellows Visit The Academy, OPIE Software, and Hanger Clinics

By Alicia Carver and Susannah Engdahl, Ph.D.

The week of June 17th was a busy one for the NAAOP Fellows. We began our week with a visit to the American Academy of Orthotists and Prosthetists, where we met the team and attended a weekly staff meeting. We learned about how the Academy compiles educational and research resources, such as the Online Learning Center, the Exam Preparation Seminars, and the Journal of Prosthetics & Orthotics, that allow members to continue learning new ways to meet patient needs. We would especially like to thank Chellie Hollis Blondes, Executive Director, and Manisha Bhaskar, Senior Director of Communications & Marketing, for taking time to share with us their roles in leading the Academy.

Immediately after our visit to the Academy, we hopped on a plane to Florida to see the Gainesville Prosthetics and Orthotics clinic and meet Paul Prusakowski, CPO, FAAOP, and CEO of OPIE Software. We learned about the history of OPIE from Paul and spent the rest of the day talking with other members of the OPIE team about their areas of expertise. In particular, we heard about the software development cycle, customer experiences with implementing the software, the knowledge-centered customer support system used when answering customer questions, and the OPIE Choice Network.

After returning from Florida, we spent two days touring the Hanger Clinic in Laurel, MD and in Washington, DC at the National Rehabilitation Hospital. We had the opportunity to sit in on several patient visits in Laurel, including with a patient who was new to that particular clinic. During this visit, we were able to observe how the prosthetist used patient-reported outcome measures to assess the patient’s current functional status and evaluated the socket fit to determine if a new prosthesis was needed. We also had a conversation with Suzi Vicino, Directory of Utilization Management Services, about successful strategies for submitting clinical documentation for reimbursement.

At the National Rehabilitation Hospital, we learned about the differences in how an O&P clinic operates when embedded in a hospital. After sitting-in on a patient visit and observing how modifications are made to a test socket, we toured the two therapy gyms at the hospital and learned how the prosthetists, orthotists, physical therapists, and occupational therapists strive to coordinate with each other to maximize their patients’ success. We would like to thank Maggie Baumer, an NAAOP board member, for organizing the trip and accompanying us during our entire time at Hanger. She introduced us to so many of her colleagues who shared their experiences.

Thank you to everyone who took the time to meet with us on our trips this past week, and for showing us such warm hospitality! We enjoyed this week very much and appreciate the efforts of everyone who made it possible.

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Mid-Summer Fellowship/Government Affairs Update

July is usually considered the middle of summer, but June has been a whirlwind month for prosthetic and orthotic policy and advocacy as the NAAOP Fellows completed the first half of their summer fellowship.  Susannah Engdahl, Ph.D., and Alicia Carver have been stellar fellows, following in the footsteps of Nicole Ver Kuilen, last year’s inaugural NAAOP Fellow.

We have spent hours on Capitol Hill advocating for the Medicare Orthotics and Prosthetics Patient-Centered Care Act, the successor to the Medicare O&P Improvement Act, a  bill that is soon-to-be-introduced.  NAAOP is coordinating with AOPA, which is taking the lead on this legislation, as well as the O&P Alliance organizations.  After multiple meetings with Members of Congress and staff thus far, and many more meetings scheduled for July, the provisions in the bill are picking up support from key members of the House and Senate.

The Fellows have learned a tremendous amount during the course of their excursions to Michigan, Iowa, and Florida.  Not only were they exposed to the clinical practice of prosthetics at Stokosa Prosthetic Clinic, but they also got a chance to walk the halls of the Michigan State Capitol to advocate on O&P issues.  A trip to Gainesville, Florida exposed them to clinical orthotics and prosthetics as well as OPIE software and the future needs of the profession in the area of data collection and outcomes.  Finally, a trip to Waterloo exposed the Fellows to OPGA’s operations as well as state politicians and policymakers.  The month ended with excursions to Hanger clinics in the local DC area where the Fellows learned about clinical orthotics and prosthetics from a large provider perspective.

Throughout the month, the Fellows visited the national offices of the Alliance organizations and spent a day with BOC, the Academy, ABC, NCOPE, and AOPA.  Each of these organizations provided a comprehensive overview of the respective missions and roles of each organization and were gracious in their hospitality.  The Fellows have gained in five short weeks a wealth of experiences and knowledge they will take with them through their advocacy and policy efforts in the future.

Special thanks to all those who support the fellowship and NAAOP.

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NAAOP Fellows Visit BOC

By Alicia Carver and Susannah Engdahl

On Monday June 10, 2019, the NAAOP Fellows spent the day at BOC headquarters in
Owings Mills, Maryland. We were warmly welcomed by BOC’s President and CEO, Claudia
Zacharias, as well as the entire BOC staff. We spent time learning about the roles each staff
member plays within the organization and were able to see the team mentality they all embrace.
We learned about their history as an accreditation organization, the makeup of their board of
directors to include practitioners from all certification categories, and their proud recognition of
the awards they have received in recent years, including nine Stevie Awards. John Schulte, CPO,
joined us and took us through the process he follows as a Facility Accreditation Surveyor and
what the BOC looks for in a facility. Everyone really showed to us the work they perform in
trying to help the O&P community work together to achieve a unified goal. We were inspired by
their commitment to quality and are thankful for all the work BOC put into planning and
executing a great day for the NAAOP Fellows!

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2019 NAAOP Fellows Begin Their Journey

NAAOP’s 2019 Fellows began their summer experience on May 28th with a week of orientation and education on O&P policy and advocacy. In addition to Washington-based advocacy, the Fellows will be traveling in June to learn about clinical prosthetics, orthotics, and policy and advocacy at the state level. They will be hosted for a day by each O&P Alliance organization and will attend the annual conference held by the Amputee Coalition in July. They will also learn about the future of O&P data collection, electronic medical records, and the Limb Loss and Preservation Registry. When in Washington, the Fellows will be focused on their main projects, which have been tailored to take advantage of each Fellow’s strengths and interests.

Susannah Engdahl recently completed her PhD in Biomedical Engineering at the University of Michigan. Having grown up using myoelectric prostheses due to congenital absence of both hands, she has a strong interest in applying science to improve functional outcomes for individuals who use prostheses. Her main project this summer will be to compile a set of evidence-based statements from the literature regarding the effectiveness of prostheses and orthoses, which the NAAOP can draw from in future advocacy work. Susannah says, “I am very excited to be working with the NAAOP this summer and to learn how I can become a more effective advocate for O&P care. Thank you to everyone who has worked to make this experience possible for me. I truly appreciate your efforts and am looking forward to the coming weeks!”

Alicia Carver is a born advocate who is passionate about advancing care that benefits O&P consumers. After congenital ankle deformity caused her to utilize orthoses during her childhood, she is now a user of limb prostheses. She brings a consumer perspective to Washington, and knows some of the challenges of accessing orthotic and prosthetic care in rural areas of the country. She has experience in state-based advocacy as a Lead Advocate for the Amputee Coalition representing the state of Indiana where she calls home. Alicia is a graduate of Ohio University with a bachelor’s degree in Technical and Applied Studies. Alicia’s main project will be to visit every Member of the key House and Senate Health Committees to promote the Medicare O&P Patient Centered Care Act. When asked what she hopes to learn during the ten-week fellowship with the NAAOP, Alicia said “I am excited to be focusing on becoming a stronger advocate as I focus on advancing the bill. I want to be a sponge and soak in this wonderful experience and gain valuable tools that I can use to be a stronger advocate on behalf of the O&P community.” She also expresses her gratitude to everyone that has worked together to organize the fellowship and the sponsors that collectively make this fellowship possible.

THANK YOU to all those who have contributed time, talent and treasure to the 2019 NAAOP Fellowship. We greatly appreciate your support.

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NAAOP Fellows Visit Michigan

By Alicia Carver and Susannah Engdahl

We just returned from a trip to Michigan, where we had the opportunity to shadow Jan Stokosa, CP, at the Stokosa Prosthetic Clinic and meet some members of the Michigan Legislature at the State Capitol building. At the Stokosa Prosthetic Clinic, we first learned about billing and some of the procedures that the Stokosa team follows when submitting insurance claims and appealing coverage decisions. Although, as individuals with limb loss ourselves, we both have experience with being denied coverage as patients, it was interesting to learn about this process from a provider perspective. We were also given a tour of prosthetic clinic, including the exam rooms and the laboratory. There was an assortment of prostheses in the laboratory that were in various stages of fabrication, which helped us see how much work is involved in designing, fitting, and fabricating a prosthesis. We were also able to observe Jan as he modified and repaired an elevated vacuum system and adjusted a socket to reduce pressure points on a patient’s residual limb.

During our trip, we talked with many patients who had diverse experiences in terms of their amputation level and history of prosthesis use. Most of these patients had experienced complications following their amputation that resulted in significant long-term pain, as well as revision surgeries to correct these issues. They also shared stories about their difficulties in getting insurance coverage for their prostheses, even though the prostheses had significantly improved their functional status, pain levels and overall quality of life. We will keep these stories in mind as we move forward with our advocacy efforts.

We also spent a full day at the Michigan State Capitol in Lansing, Michigan visiting with the Michigan legislature. We were introduced to Jack Schick with Karoub Associates. As a lobbyist and an amputee himself, he gave a tutorial in lobbying 101. We had scheduled meetings with Senator Vanderwall and Representative Vaupel. Senator VanderWall was kind enough to take us onto the floor of the Senate chamber. We learned what it is like to be a state lobbyist and the art of grabbing the attention of members of the House and Senate to get a few moments of their time. We are grateful to Jan and Mary Stokosa for being such gracious hosts, to the staff at Stokosa Prosthetic Clinic, and to everyone who made us feel so welcomed on this trip and shared their time with us.

  • Written by NAAOP

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.

Learn More | Register | Book Your Room | Schedule

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