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    • Month: December 2014

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    Additional Analysis on the CMS Final Rule Regarding Supplier Enrollment, Accreditation Requirements, DMEPOS Competitive Bidding, and Medicare Prior Authorization

    Wednesday, Dec 03, 2025

    $10 Million for O&P Outcomes Research Included in the Cromnibus Bill, and RAC Concerns Addressed

    Great news for O&P outcomes research! The $1.1 trillion combined continuing resolution and omnibus appropriations bill (the “cromnibus” bill) enacted December 13 to keep the government running includes a Department of Defense (DoD) section with an additional $10 million for O&P outcomes research funding.  This was also included in last year’s budget and we are especially grateful for AOPA lobbyist Catriona Macdonald, who has done such a spectacular job in transitioning this from a one-time item to being multi-year, and hopefully a mainstay of the federal budget! This is another good win for AOPA and its members. This news was especially impressive given how many cuts and other programs were squeezed out of the DoD portion of the bill.

    Legislators also signaled that the efforts of AOPA and many others have been successful in raising very significant concern regarding the Medicare RAC audits, and the unconscionably long (and illegal) delays in allowing providers to access an Administrative Law Judge (ALJ) hearing.  Although there is no substantive fix included, an additional $5 million was added to ALJ funding. Greater help, while by no means certain, could come in new Medicare legislation in 2015. The good news is that Congress did ‘put down a marker’ on their concern in the following language included in the bill:

    Recovery Audit Contractors (RACs). There is concern that the CMS RAC program has created incentives for RACs to take overly aggressive actions. Information received from the Office of Medicare Hearings and Appeals (OMHA) indicates that about 50 percent of the estimated 43,000 appeals were fully or partially overturned at its level. The fiscal year 2015 budget request should include a plan with a timeline, goals, and measurable objectives to improve the RAC process. In addition, CMS is expected to work with Congress and stakeholders to identify challenges and additional reforms. Further, CMS should establish a systematic feedback process with the OMHA, CMS programs, and the RACs to prevent the appearance that RACs are selecting determinations to increase their fees. The CMS is urged to stay focused on improvements to all “operations” that prevent improper payments in lieu of chasing dollars after the fact.

    AOPA Submits Comments on OMHA’s ALJ Backlog and Increased Requests for Hearings

    Following the October 29 Medicare Appellant Forum hosted by the Office of Medicare Hearings and Appeals (OMHA), the Department of Health and Human Services (HHS) opened a comment period to solicit suggestions for addressing the growth in the number of requests for Administrative Law Judge (ALJ) hearings, and to help to clear the backlog of pending cases.

    As you may be aware, the OMHA office is receiving approximately 14,000 appeals per week, compared to the 1,250 per week in 2011 prior to the “Dear Physician” letter and subsequent increase in auditing activities. While OMHA has received a modest budget increase to expand operations, and are implementing several pilot programs, the O&P Community has yet to feel any relief. The current wait time for an ALJ Hearing is 414 days from the time of the request until the decision.

    In our comments, AOPA emphasized the following points:
    1.  Recovery Audit Contractor (RAC) Activities Must be Re-Focused
    2.  CMS Should Offer Orthotic and Prosthetic Providers the Opportunity to Voluntarily Settle Claims that are Awaiting an ALJ Hearing Using a Statistically Valid Extrapolation Process
    3.  OMHA Should Overturn Claim Denials that Cannot be Scheduled for an ALJ Hearing Within 90 Days of a Hearing Request
    4.  Coordinated Actions Needed by HHS, CMS and OMHA
    5.  OMHA Must be Funded at a Level that Supports its Increased Workload

    You can read the full comments submitted here.

    2015 Medicare DMEPOS Fee Schedule Released

    The Centers for Medicare and Medicaid Services (CMS) has released the 2015 Medicare DMEPOS fee schedule, effective for claims with a date of service on or after January 1, 2015.

    The net Medicare fee increase for O&P services for 2015 is 1.5%.  This is based on a 2.1% increase in the consumer pricing index for urban areas (CPI-U) from June 2013 through June 2014, minus the annual productivity adjustment, set at 0.6% for 2015.

    The complete 2015 DMEPOS fee schedule may be downloaded here.