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    Reminder Regarding RAC ADR Limits for O&P Services

    AOPA would like to remind its members that revised limits for Additional Documentation Requests (ADRs) for RAC audits involving O&P claims were implemented as of April 3, 2013.

    While the ADR calculation remains unchanged at 10% of claims submitted during the previous year, divided by 8, for each 45 day period, CMS has limited the number of ADR requests for O&P providers to a maximum of 10 ADR requests every 45 days.

    AOPA has received several reports where members have received ADR requests after April 3, 2013 that exceed the maximum of 10.

    If you receive more than 10 ADR requests from a RAC auditor within a 45 day period, please contact the RAC contractor immediately to challenge the request.  In addition, please contact Joe McTernan so that AOPA may address this issue with CMS directly.

    Compassionate Care Access Offered to Boston Marathon Amputee Victims

    ALEXANDRIA, VA, – The American Orthotic and Prosthetic Association (AOPA) is leading a coalition to provide access to care for uninsured/underinsured amputee victims of the Boston Marathon Bombing to assure that all victims “will walk and run again”.

    Leaders of manufacturer and patient care facility members of AOPA and coalition partners have pledged to connect these amputees and those with related mobility impairment with the needed specialized care for those who may not have any health insurance or the means to assure access to the needed care and artificial limbs, customized bracing and mobility assistive devices. The prosthetic and orthotic care and componentry will be provided at no cost to those patients.

    The coalition of AOPA members and those affiliated with the American Academy of Orthotists and Prosthetists, the National Association for the Advancement of Orthotics and Prosthetics and the Amputee Coalition have mobilized their national membership networks to provide care access and support. 

    Participate in the Second Annual AOPA OPTA Technical Fabrication Contest

    Compete to fabricate a partial foot Prosthosis in the Second Annual AOPA OPTA Technical Fabrication contest and gain international recognition at the 2013 O&P World Congress.  In addition you will have the opportunity to win a cash prize and students can generate special recognition for their school.

    Register today!

    For contest guidelines, judging criteria and more, contact Steve Custer via email at or (571) 431-0810.

    Sponsored by AOPA, OPTA, OttoBock, ABC and Cascade.

     

    CMS Reverses Its Position on Replacement of a Prosthesis Without a New Prescription

    On April 24, 2013, CMS announced that Medlearn Matters Article SE1213 had been revised to remove a statement that indicated that a prosthesis could be replaced without a new order from a physician as long as there was no upgrade from the previously ordered prosthesis.  This statement was originally added to Medlearn Matters Article SE1213 in a revision dated June 7, 2012.

    AOPA is deeply concerned about the removal of this statement as it represents another example of the failure of CMS to provide reliable coverage guidance to providers of orthotic and prosthetic devices.  When the statement was initially added to the article in June of 2012, AOPA was concerned that it seemed to create conflict with Chapter 15, section 110.2 of the Medicare Benefit Policy Manual which addresses replacement of DMEPOS and clearly states that a new order is necessary to reaffirm the medical necessity of the item.  While the removal of the statement from the Medlearn Matters article seems to resolve this conflict, the fact remains that for almost a year, there was a CMS publication in circulation that provided guidance that was in direct conflict with its own Benefit Policy Manual.  The revision of the article to remove this statement effectively means that in CMS’ eyes, the statement never existed.

    AOPA was wary of this statement from its initial publication and has continued to recommend that a new order should be obtained when replacing any O&P device regardless of the reason for replacement.  With the removal of the statement from the Medlearn Matters Article regarding replacement of a prosthesis without obtaining a new order, AOPA must reiterate its recommendation to obtain a new order when replacing any O&P device.

    AOPA will express its concern to CMS regarding the confusion that publication and subsequent removal of this statement from the Medlearn Matters Article has caused.

    Link to April 2013 (current) version can be found here.

    Link to June 2012 (previous) version can be found here.

    Questions regarding this issue may be directed to Joe McTernan or Devon Bernard.

     

    PECOS Edits for Ordering/Referring Physicians is Delayed

    CMS has announced that Phase 2 of the PECOS edits for ordering/referring physicians is now delayed and a new effective date has not been announced. Claims where there is no PECOS record for the referring/ordering physician were set to be denied on May 1, 2013.

    This means that your current Medicare claims will not be subject to edits that will ensure that the referring /ordering physician has an active profile in the Provider Enrollment Chain Ownership System (PECOS).  Medicare will continue to process claims normally and will still provide you with notification if an ordering/referring physician doesn’t have a PECOS record.

    The complete Medicare announcement may be viewed here.

    Questions regarding this issue may be directed to Joe McTernan or Devon Bernard.

    Jurisdiction D DME MAC Releases Pre-Payment Review Results

    Noridian Administrative Services, LLC, the Jurisdiction D DME MAC has recently released results of two ongoing widespread pre-payment reviews; one for diabetic shoes described by A5500 and the other for AFOs described by codes L4360, L1960, and L1970.  All reported results involve claims that were reviewed between December, 2012 and March 2013.

    For diabetic shoes described by A5500, the overall error rate was reported as 92%.  A total of 2,240 claims were reviewed with 1,984 claims denied.  The most common reason for claim denial (26%) was lack of documentation in the medical record that supported one of the 6 conditions secondary to diabetes that must be present in order to warrant Medicare coverage of diabetic shoes.  Other reasons for claim denial included lack of documentation of a visit with the certifying physician (20%), no documentation received to support medical necessity of the shoes (11%), and lack of documentation of an in person fitting and evaluation visit with the supplier of the shoes (7%).  Based on the overall claim denial rate of 92%, Jurisdiction D has announced that the widespread pre-payment review for A5500 will continue.

    For AFOs described by L4360, L1960, and L1970, the reported error rates were 84%, 86%, and 80% respectively.  For L4360, the majority of denials (23%) were due to missing proof of delivery documentation with another 22% denied due to a lack of a dispensing and/or detailed written order.  For L1960 (22%) and L1970 (25%), the majority of denials were due to lack of documentation in the physician’s records supporting the use of a custom orthoses rather than a prefabricated orthosis.  An additional 21%-22% of claims for L1960 and L1970 were denied due to a lack of documentation supporting one of the five criteria necessary for selection of a custom fabricated orthosis.  As a result of the overall high denial rate, Jurisdiction D has announced that the widespread pre-payment review for L4360, L1960, and L1970 will continue.

    Questions regarding this issue may be directed to Joe McTernan or Devon Bernard.

     

    Compassionate Care Access Offered to Boston Marathon Amputee Victims

    ALEXANDRIA, VA, April 22, 2013 – The American Orthotic and Prosthetic Association (AOPA) is leading a coalition to provide access to care for uninsured/underinsured amputee victims of the Boston Marathon Bombing to assure that all victims “will walk and run again”.

    Leaders of manufacturer and patient care facility members of AOPA and coalition partners have pledged to connect these amputees and those with related mobility impairment with the needed specialized care for those who may not have any health insurance or the means to assure access to the needed care and artificial limbs, customized bracing and mobility assistive devices. The prosthetic and orthotic care and componentry will be provided at no cost to those patients.

    The coalition of AOPA members and those affiliated with the American Academy of Orthotists and Prosthetists, the National Association for the Advancement of Orthotics and Prosthetics and the Amputee Coalition have mobilized their national membership networks to provide care access and support.

    AOPA Continues Dialogue with OIG Regarding L0631 Spinal Orthoses

    In an April 19, 2013 letter to Inspector General Daniel Levinson and Deputy Inspector General for Evaluation Stuart Wright, AOPA addressed several concerns regarding assertions that were made in the OIG response to AOPA’s comments on the December 2012 OIG report entitled Medicare Supplier Acquisition Costs for L0631 Back Orthoses.

    AOPA provided initial comments on the report in a January 8, 2013 letter and received a response on April 3, 2013.  The April 19th letter was sent in order to express AOPA’s concern regarding several statements that were made by the OIG in its initial response.  Of specific concern to AOPA was a statement in the OIG response that, “there are no requirements regarding the type of supplier that may provide an L0631; beneficiaries can obtain one from any enrolled Medicare supplier provided that they have a written order from a physician.”  The OIG implies that this statement justifies the inclusion of L0631 in future rounds of competitive bidding as a means to reduce Medicare reimbursement.  AOPA does not agree that L0631 should be classified as an off the shelf orthosis subject to inclusion in competitive bidding and that it requires the clinical knowledge and experience of a properly trained healthcare professional, such as an orthotist, to ensure a quality clinical outcome for the patient.

    AOPA also expressed its concern that both the original report and the April 3rd OIG response conveyed an apparent lack of familiarity with qualified provider language provision of section 427 of the BIPA Act as well as the OIG’s own report on CMS’ failure to promulgate regulations in order to Implement them.  AOPA strongly reiterated its position that proper regulation of existing legislation would provide a better solution than exposing Medicare beneficiaries to substandard care by unqualified providers by including L0631 in future rounds of competitive bidding.

    AOPA will continue its dialogue with the OIG in an effort to ensure that Medicare beneficiaries continue to have access to quality healthcare provided by properly trained and qualified professionals.

    AOPA Letter to Tavenner and Sebelius Further Challenges “Dear Physician” Letter

    AOPA’s counsel on CMS matters, Tom Mills of the law firm Winston and Strawn, has issued a second letter to HHS Secretary Sebelius and CMS Acting Administrator Tavenner again seeking withdrawal of the “Dear Physician Letter” which unleashed the horrendous increase in RAC and other audits as well as burdensome prepayment reviews.  All of these actions by CMS contractors have delayed or prevented timely patient services in O&P and disrupted cash flow so completely that many O&P patient care facilities have closed their doors after decades of service or downsized staff dramatically.

    In addition to requesting withdrawal of the August 2011 “Dear Physician Letter,” Mr. Mills requested further CMS correction “by instructing CMS contractors to treat the prosthetists notes as part of the medical record, and by insisting that CMS contractors explain in detail the basis for any disallowance of claims for prosthetic devices.”

    AOPA continues to maintain the “Dear Physician” letter was “improperly issued” without following the necessary procedures allowing public comment.  The letter also points out that “CMS’ own Manual recognizes that prosthetists records are entitled to the same deference as physician records.”

    It goes on to say that “CMS’ justification for now ignoring its own Manual and refusing to treat prosthetists’ notes as part of the medical record is that prosthetists may have a ‘vested financial interest in the outcome of the claim decision.’  This justification is ironic, given the vested financial interest CMS contractors have in disallowing the claims they are hired to review.  As AOPA has pointed out, there are scores of situations in which physicians make judgments that arguably could be affected by self-interest, yet CMS does not challenge those judgments.”

    Click here for the April 15, 2013 letter to HHS Secretary Sebelius and Administrator Tavenner and here for the December 14, 2012 letter to Marilyn Tavenner.

    This second Attorney Mills letter references letters AOPA has also sent to CMS official, George G. Mill, Jr., Director, Provider Compliance Group, which manages the CMS contract auditors.  Read AOPA’s letters to George Mills and the responses.

     

    AOPA Members Rally to Secure 35 Representatives to Sign-On to HHS Secretary Sebelius Letter

    Those who attended the AOPA Policy Forum March 12-13 started the effort in their Congressional visits to persuade their Representatives to sign-on to a letter from Rep Duckworth (D-IL) and Rep. Guthrie (R-KY) to HHS Secretary Sebelius expressing concerns about CMS audit procedures.  A follow-up campaign, by directed at the entire AOPA membership, generated action by 1,270 members who sent emails to 380 Congressional offices.

    While the goal as always in this kind of effort was to get every one of the 435 offices on the House side of Capitol Hill to sign-on, the campaign did achieve excellent results with thirty-five Representatives joining the sign-on effort.  Several members of Congress opted to author their own letter and asked AOPA for a draft.  That reflects a policy of some lawmakers to not join “sign-on” efforts to make sure they control the message and not be in a position to have something attributed to them that may come back and haunt them in a future campaign.

    Another mark of success is the bipartisan nature of the support with 19 Democrats and 16 Republicans joining in voicing their concerns.

    In addition to Rep. Guthrie and Duckworth, the list of lawmakers who joined the effort and deserve a note of thanks include: Michele Bachmann (R-MN), Bruce Braley (D-IA), Corrine Brown (D-FL), André Carson (D-IN), Steve Chabot (R-OH), Danny K. Davis (D-IL), Keith Ellison (D-MN), Michael G. Fitzpatrick (R-PA), Sam Graves (R-MO), Jared Huffman (D-CA), Duncan Hunter (R-CA), Bill Johnson (R-OH), William R. Keating (D-MA), Derek Kilmer (D-WA), Peter King (R-NY), Tom Latham (R-IA), Robert Latta (R-OH), Billy Long (R-MO), Dan Maffei (D-NY), James Moran (D-VA), Chellie Pingree (D-ME), Mark Pocan (D-WI), Mike Quigley (D-IL), Nick J. Rahall (D-WV), Phil Roe (R-TN), Todd Rokita (R-IN), C. A. Dutch Ruppersberger (D-MD), Aaron Schock (R-IL), Carol Shea-Porter (D-NH), Eric Swalwell (D-CA), Lee Terry (R-NE), Frederica S. Wilson (D-FL) and Ted Yoho (R-FL)