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    Announcing AOPA’s First-Ever O&P Rising Stars

    Thursday, Oct 16, 2025

    Reminder: PECOS Edits for Referring/Ordering Physicians Scheduled for Implementation on May 1, 2013

    The Centers for Medicare and Medicaid Services (CMS) has announced that it will implement Phase 2 of the PECOS referring/ordering physician edits for claims submitted on or after May 1, 2013.   What this means is that claims for services ordered by a physician or other eligible provider who does not have an active enrollment file in the PECOS system will be denied.

    AOPA has recently received concerns from members regarding a CMS requirement that  referral sources must not only be registered in PECOS, but also must indicate that they will prescribe orthotic and prosthetic services in order for claims for services they prescribed to be processed by the DME MACs.  While CMS has indicated that in addition to registering in PECOS, prescribing providers must be eligible to prescribe DMEPOS, there is currently no requirement that prescribing providers indicate that they will prescribe O&P services specifically.  The specialty types listed as eligible to prescribe DMEPOS include the following:

    -M.D. -Physician Assistant
    -D.O. -Certified Clinical Nurse Specialist
    -Doctor of Dental Medicine or Dental Surgery -Nurse Practitioner
    -Doctor of Podiatric Medicine -Doctor of Optometry

    The list above represents no change to the historical list of provider specialties that may prescribe DMEPOS, including orthotic and prosthetic services so it’s impact on O&P providers should be minimal.

    It remains important that AOPA members confirm that their referral sources are properly enrolled in PECOS in order to avoid unnecessary claim denials on or after May 1, 2013.

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

    AOPA Plans to Testify in Upcoming SBA Hearing on Regulatory Fairness

    There is an upcoming Regional SBA Hearing being held in Seattle, WA on June 6th titled “Regulatory Fairness Hearing for Small Business.”  AOPA will be testifying on behalf of our members on the RAC and Pre-payment audit practices jeopardizing the economic viability of our members.

    This hearing is being held by the U.S. Small Business Administration, Office of the National Ombudsman. The National Ombudsman assists small businesses with unfair and excessive regulatory enforcement by federal agencies including repetitive audits or investigations, excessive fines, penalties, retaliation or other unfair regulatory enforcement actions. The National Ombudsman acts as a “troubleshooter” between small businesses and federal agencies by receiving comments and complaints from small businesses and then directed those comments and complaints to the appropriate federal agency for a high-level review.

    The hearing is designed to provide small business owners, community and business leaders with an opportunity to discuss issues regarding Federal Regulatory Compliance and enforcement. While this hearing is one of the regularly held hearings mandated by the law that set up the Regulatory Fairness Office and is designed as a general session for all kinds of small business government abuse issues, we plan to use this opportunity to voice concerns about the CMS regulatory issues plaguing O&P small businesses.

    The SBA will also be holding another Regulatory Fairness Hearing on June 21, 2013 in Davenport, Iowa from 8:30 am- 11:30 am.

    For additional information on the hearing and the SBA’s role in this process view:

    Policy Forum Makes Big Impact on Raising Congressional Concerns over RAC Audits

    AOPA Executive Director, Tom Fise, brought the Board of Directors up to date in a recent email on how AOPA members attending the Policy Forum took the lead in urging their legislators in the House of Representatives to sign-on to the letter Rep. Tammy Duckworth and Rep Brett Guthrie will send to HHS Secretary Sebelius.  Subsequently, all AOPA members were urged to contact their legislators and to request they sign-on to the Sebelius letter.

    Click here to read the letter to Secretary Sebelius.

    EXCERPTS FROM FISE EMAIL UPDATING AOPA BOARD ON RAC AUDITS

    “With March drawing to a close, it makes sense to provide an update on AOPA’s and related efforts on the RAC/pre-payment audit issues.  In terms of this issue, it was very fortuitous that we decided to hold the Policy Forum earlier than usual this year, as a great deal has happened since we saw most of you at the AOPA Policy Forum, March 12-13.

    “Let me start with background on RAC issues in hospitals.  Many of you are probably familiar with the fact that a few months back the American Hospital Association sued CMS challenging its RAC audit policies.  The specific dispute is a bit different from ours but related.  RAC auditors have roundly challenged claims involving patients who were admitted as inpatients and received certain procedures, claiming the admission was improper, clawing back the entire Medicare payment to the hospital with the assertion that the procedure could have been done on an outpatient basis.  Hospitals have massively appealed these audit results up the chain to the ALJ claiming that even if the auditor is correct regarding the admission decision, Medicare ought to at least allow the payment the hospital would have received if the patient had received the procedure on an outpatient basis at the hospital.

    “I have been told that these appeals to ALJ have succeeded in securing partial payment in 90-95 percent of cases that have gone that far.  On March 13, CMS released its proposed regulations to implement such partial payment AND also issued a new administrative policy that they would start making the partial payment immediately, even before the conclusion of the rulemaking process for the new regulation, in any such case where an audit contested the full inpatient hospital tab (see email attached).  This is a very important precedent that was achieved after the AHA filed suit, and the AHA gave nothing in return for the CMS commitment to the new regulation and interim administrative policy that approved partial payment, i.e., AHA did not withdraw its suit against Medicare.

    “You may also recall that on March 8, just before the Policy Forum, we had written four letters to CMS audit/DME MAC contractor chief George Mills, questioning several policies those contractors had implemented (click here to see letters).   I was not surprised to receive an email from George Mills, responding to two of the four letters (Letters one & two) we had delivered to him.  The AOPA letters/requests on the issues of K-level and the legitimacy of the prosthetist’s notes remain pending in front of George Mills, still awaiting action.

    “There remain a good many items in motion, energized largely by the AOPA Policy Forum.   Reps. Duckworth and Guthrie circulated a “Dear Colleague” letter to all Members of the House, encouraging them to sign-on to the letter to Secretary Sebelius.  AOPA has mounted a strong outreach both to Policy Forum attendees and to all AOPA members, offering an easy pathway for them to contact their House Representative urging them to exercise the opportunity to Sign-on  to the letter.  Within the past 5 day AOPA members have sent letters to approximately 250 Congressional offices seeking endorsement of the Duckworth/Guthrie letter.  While many members of Congress are reluctant to ‘sign-on’ to such joint letters,  we are still hopeful of securing commitments from a good number of House members to sign-on in advance of the April 10 close-out date when the letter will be finalized and delivered by Duckworth and Guthrie, with as many signatures as can be garnered–so the heat is building at CMS

    “The high level of activity on the RAC and pre-payment audit issue, especially since the Policy Forum seems to have prompted some confusion among CMS staffers.  For example, we’ve been informed by Hill staffers that CMS has been representing to Congressional staffers that AOPA is already working with CMS on their planned physician template rule making (we will work with them if and when they ask us to–and odds are they will ask–but as yet they haven’t).”

    End of Fise Email

     

    HHS Inspector General Takes Swipe at L0631

    Writing in AARP The Bulletin, Daniel R. Levinson repeats a faulty assertion first made in the Office of Inspector General Report of December 2012 that Medicare paid an average of $919 for L0631 coded back braces that could be bought on the Internet for $191.  The Medicare reimbursement was supposed to include ongoing clinical care (fitting, refining, patient training, etc;) by a certified orthotist or other qualified healthcare professional.  Yet, the OIG report says one-third of the claims record no evidence that fitting or other ongoing care was provided.

    Mr. Levinson’s report further recommended that these devices should either only be provided by competitive bidding or Medicare reduce the reimbursement to the $191 Internet pricing.  Neither recommendation makes sense, even if the facts were correct.

    After reviewing the OIG Report, AOPA wrote Mr. Levinson January 8, 2013 pointing out competitive bidding was not an option because the statute defines off-the-shelf orthotics as those devices which only require “minimal self adjustment” by the patient.  The L0631 back braces do not qualify and to include them would violate the law.

    AOPA also pointed out limiting reimbursements to the “Internet” price would eliminate the clinical care and patient training required to ensure the proper functionality of the device.

    If the AARP article is any indication, these and other arguments AOPA made apparently fell on deaf ears or Mr. Levinson and his staff decided either not to read, or not to recognize the facts outlined in AOPA’s letter which was backed up by solid statistics from Medicare’s own database.

    Click here for letter and here for data referenced in letter to read the original January AOPA response to the OIG December Report.  A further response is being prepared for the editors of AARP The Bulletin to set the record straight.

    HHS OIG Reports have been the trigger for most of the reimbursement woes visited on the O&P field as members will remember the August 2011 OIG Report on lower limb prostheses which in turn resulted in the “Dear Physician” letter on required documentation that has plagued O&P providers.

     

    AOPA’s Concerns Prompts CMS to Modify Limits for RAC Audits

    AOPA’s continuing conversation and efforts to convince CMS of the cash flow killing harm to patient care and member patient care facilities imposed by the pervasive and aggressive RAC audits together with aggressive AOPA member advocacy with their legislators flowing from the Policy Forum appears to have borne some fruit.

    The Centers for Medicare and Medicaid Services has announced that, effective April 3, 2013, it has modified the number of Additional Documentation Requests (ADRs) that a RAC auditor may make for DMEPOS suppliers.

    For most DMEPOS suppliers, the limits remain unchanged from last year. The number of ADRs a RAC may make per 45 days is limited to 10% of all claims submitted under a single Tax ID for the previous calendar year, divided by 8.

    For suppliers who are classified in categories 52, 53, 56, or 57 however, there is a limit of no more than 10 ADR requests per 45 days. The provider taxonomy codes mentioned above are defined as follows:

    • 52—Medical Supply Company with Prosthetist
    • 53—Medical Supply Company with Orthotist-Prosthetist
    • 56—Individual Certified Prosthetist
    • 57—Individual Certified Prosthetist-Orthotist

    The fact that CMS has modified the RAC ADR guidelines to include a limit of no more than 10 ADR requests for claims from companies providing prosthetics is a significant development in AOPA’s efforts to challenge the egregious and aggressive audit practices that RAC auditors have been using. While it does not represent, in any respect, a comprehensive solution to the challenges that RAC audits represent, it does represent an acknowledgement of the negative impact RAC audits have had on the provision of medically necessary services by qualified O&P professionals.

    AOPA has contacted CMS and requested that they also consider a similar limit of no more than 10 ADRs per 45 days for suppliers classified as follows:

    • 51—Medical Supply Company with Orthotist
    • 55—Individual Certified Orthotist

    CMS has indicated that it will consider including these categories in a future update to the RAC ADR limits. If and when this change is made, AOPA will notify its membership.

    AOPA can assist members to ensure that their organization is enrolled in Medicare under the proper provider taxonomy code. Questions on how to do this or any other questions regarding this issue may be directed to Joe McTernan or Devon Bernard.
    This action is distinct from CMS’ response to AOPA’s letter of March 8, referenced in a prior AOPA Smartbrief, notifying CMS that Performant Recovery, Inc., the Jurisdiction A RAC contractor, was incorrectly applying the provider based ADR limit calculation to O&P suppliers resulting in more ADR requests than regulations allow. CMS has corrected this situation and Performant Recovery has rescinded RAC audits that exceeded the limits of the supplier based calculation. If you are interested in reviewing those communications, they are accessible at: March 8th letter & CMS Response.

    AOPA Partners with Canadian Association of Prosthetics and Orthotics for the World Congress

    WASHINGTON, DC – The American Orthotic & Prosthetic Association (AOPA) is pleased to announce that The Canadian Association of Prosthetics and Orthotics (CAPO) is the latest organization to join as an official partner of the 2013 O&P World Congress.

    “CAPO evolved from a national association established in 1955 to provide a national, professional organization with a strong voice to represent the interests of the growing number of practitioners in the fields of prosthetics and orthotics across Canada.” Their representation of the entirety of Canada mirrors AOPA and is a great opportunity for our members to become inspired by what the O&P profession is striving for just across our Northern boarder.

    CAPO joins as the fourth partner in the growing assembly of North American representation for the 2013 World Congress. The worldwide partnerships include the following organizations: The U.S. National Member Society of the International Society for Prosthetics and Orthotics (USISPO); the German Association of Orthopaedic Technology/Con.fair.med; and the Amputee Coalition.

    The World Congress will bring together prosthetists, orthotists, physicians, technicians, scientists, researchers, engineers, programmers, clinicians, pedorthists, fitters, physical therapists, technicians and other professionals. This diverse community, focusing on different aspects of orthotics and prosthetics, will provide a unique and powerful environment to advance the field of O&P. The 2013 World Congress will be held Sept. 18-21, 2013 at the Gaylord Palms Resort, Orlando, Florida, USA. Community members may now register online, mail or via fax.

    To learn more about CAPO visit: www.prostheticsandorthotics.ca. To learn more about the World Congress visit http://www.opworldcongressusa.org.

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