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    AOPA Emphasizes Patient Access to Care When Urging the Department of Commerce to Exclude Custom O&P in National Security Probe

    Monday, Oct 20, 2025

    AOPA Submits Comments on AHRQ Systematic Review of Lower Limb Prostheses

    On December 1, 2016 the Agency for Healthcare Research and Quality (AHRQ) announced that it was soliciting public comment on the key questions that would be used in its previously announced systematic review of clinical literature relative to lower limb prostheses.  Comments were to be submitted no later than 11:59 pm on December 20, 2016.

    AOPA, with significant input from its Medical Advisory Board and its expert steering committee, as well as AOPA Board members, developed and submitted detailed comments that addressed both the systematic review in general as well as responses to the 8 key questions on which the AHRQ had requested comments.  In addition to its own comments, AOPA actively contributed to comments developed and submitted by the O&P Alliance, and AOPA expressed in our submission to AHRQ that we also join in and support the comments of the O&P Alliance of which AOPA is a member.  Many other organizations and individuals have also submitted comments on this very important topic.

    Read the AOPA comments.

    Questions regarding the AOPA submission may be directed to Joe McTernan at jmcternan@aopanet.org.

    CMS Announces Initial Implementation of Prior Authorization Program-No Prosthetic Codes Included

    On December 19, 2016, the Centers for Medicare and Medicaid Services (CMS) announced the initial implementation of the Medicare prior authorization program that was authorized through the final rule published on December 30, 2015.

    As expected, CMS has chosen a cautious approach in implementing its prior authorization program.  The initial list of codes subject to prior authorization only contains 2 codes, both of which describe power wheelchairs.  The two codes selected are:

    -K0856–Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds; and
    -K0861–Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds.

    In addition to limiting the number of codes initially subject to prior authorization, CMS has chosen to implement the prior authorization process in two phases.  The first phase will be implemented on March 20, 2017 and will require prior authorization for the two codes above in one state within each DME MAC jurisdiction.  The second phase will be implemented on July 17, 2017 and will expand the prior authorization program for the two codes above nationwide.

    While the initial implementation of the Medicare prior authorization program does not include any lower limb prosthetic codes, the expectation remains that prior authorization for most lower limb prostheses will become reality at some point in the future.

    AOPA will continue to monitor developments and communicate any new information to its members.

    Read the CMS announcement.

    Questions regarding this issue may be directed to Joe McTernan at jmcternan@aopanet.org or Devon Bernard at dbernard@aopanet.org

    Congress Adjourns-No Final Action on Medicare O&P Improvement Act or Other Medicare Issues in Final Continuing Resolution

    Capitol rectangleThe 114th Congress completed its work in a “beat the clock” enactment around 11:30 pm on Friday evening, December 9 by the Senate passing a Continuing Resolution (CR) just 30 minutes before the government would have shut down. That Continuing Resolution will keep the U.S. government operating through April, and without enacting the provisions of the Medicare O&P Improvement Act (H.R. 1530/S.829). As the saying goes, “close doesn’t count,” but the story of how remarkably close we did come to enacting the bill does both reflect how very different this Congress was from the O&P vantage point, as well as holding some significant promise that we’ll get this done, hopefully early in the next Congress.

    H.R. 1530/S. 829 would accomplish four major steps: (1) reiterate, expand and underscore the mandate for CMS to implement the qualified provider/accreditation provisions first established in Section 427 of BIPA 2000; (2) establish the orthotist/prosthetist notes as a legitimate part of the medical record for purposes of establishing Medicare medical necessity; (3) complete statutory separation of O&P from DME; and (4) further clarify the already “bright line” defining off-the-shelf orthotics (and thereby limiting potential eligibility for competitive bidding) to devices that can be used by the patient with ‘minimal self-adjustment’ by “the patient and no other person.” We had some strong winds form behind our legislation this Congress, an uprising of AOPA/O&P enthusiasm that was ramped up with the AOPA Policy Forum in April 2016, and the legislation-writing Congress headed by former Senator Bob Kerrey, which gave all of you the opportunity to actually write the essential bill components-the things you and your patients most need in daily practice! Add to that remarkably strong advocacy by all of our legislation sponsors, and particularly relentless efforts by Senator Chuck Grassley (R-IA) in the Senate and Glenn (G.T.) Thompson in the House, and O&P professionals. Folks in the O&P community itself emerged as leaders in the fight, calling friends in Congress and calling in favors-AOPA Past President Tom Watson, just elected as Mayor of Owensboro, Kentucky has been incredibly vigilant and supportive with his outreach within the powerful Kentucky delegation. AOPA President Michael Oros, was one of several O&P professionals who held events to advance the candidacy of now Senator-Elect Tammy Duckworth. The efforts of AOPA’s capable lobbying team was supplemented by coordination with lobbyists like former Congressman Scott Klug who represents Hanger, and the legislative arms of Ottobock and other manufacturing companies enlisted in the efforts.

    All of this resulted in a much greater awareness in Congress of our concerns and needs. Our bill qualified as the Triple Crown of what is needed to help pass health care legislation: (1) no one opposes what we’ve asked for; (2) the Congressional Budget Office says it won’t cost the government any money; and (3) thanks to Senator Kerrey’s efforts, even the CMS Administrator, Andy Slavitt said he supports the bill. So, why didn’t it pass this Congress? Medicare changes don’t get enacted as stand alone bills. They end up getting grouped together and they are typically enacted in one or two major bills that move, usually at the end of the Congress. There were two such pieces of year-end legislation. The 21st Century Cures Bill had a few Medicare items attached, but the “rules” were that only things that had already passed in either the House or Senate could be added, and we didn’t fit that criterion. The other was inclusion of our provisions in the final Continuing Resolution (CR) to fund the government. Everyone on the O&P team pitched into a full-court press effort to get into the CR. We ran into a roadblock in getting final sign-off from the Congressional Budget Office (CBO) confirming that there would be $0 cost, that delayed us. But in the end, on Tuesday afternoon December 6, we received CBO clearance, and also received confirmation from Senate leadership that if any Medicare provisions got included in the Continuing Resolution, one or all of our S. 829 provisions would be among them. Later that day, the draft of the Continuing Resolution was released via the House Appropriations Committee, but a decision had been made in the House not to include any Medicare provisions.

    So, while disappointed that we did not cross the finish line, all of the efforts by so many in, and on behalf of the O&P field in 2016 have advanced our issues and prospects greatly, and we must carry that momentum forward into 2017. In January, we will have a new President, new incumbents in the offices as Secretary of HHS and Administrator of CMS, and the new 115th Congress will be sworn into office. As a formal matter, that means everything starts over-new bills will need to be introduced in both Houses, and new Committees will be seated with responsibility over Medicare and other health matters. But the energy and commitment remains with many with whom we have worked to finish the work that came so close to completion this year. Please mark May 24-25 on your calendar for our 2017 AOPA Policy Forum, and let me quote a message I received from former Senator Kerrey just yesterday-“We are in very good shape to get this done in 2017…Let’s keep pushing!!!”

    Thanks for your support,
    Thomas F. Fise Signature

    Tom Fise, JD
    Executive Director

    U.S. District Court Grants Judgement to Hospital Association, Mandates HHS Remedial Action to Reduce ALJ Waiting Period

    In mid-2014, the American Hospital Association (AHA) filed suit against HHS challenging the long delays—far in excess of the statutory limit of 90 days—before RAC audit appeal cases are heard by an administrative law judge (ALJ).  Early on, the District Court ruled against AHA, but was overruled by the Court of Appeals.  In now ruling in favor of AHA, the Court clearly demonstrated its impatience with the long delays, but also was careful not to try to force the hand of HHS with specific steps.  Instead, the Court adopted a remedy with four threshold dates at which HHS is instructed to have reduced the back-up in ALJ hearings by set percentages.

    Namely,
    By December 31, 2017 – 30% reduction in the backlog
    By December 31, 2018 – 60% reduction in the backlog
    By December 31, 2019 – 90% reduction in the backlog
    By December 31, 2020 – 100% reduction in the backlog

    AHA had also proposed the remedy that the Court automatically issue rulings for defendants as January, 2021 for any cases where there was a backlog of more than one year.  The Court refused that request, at least for the present, though it left the door open to reconsider that if HHS fails to meet the above targets.

    How will this potentially impact O&P RAC claims?  O&P RAC claims comprise a disproportionately high percentage of all Part B RAC claims.  The lawsuit by AHA involved Part A hospital claims.  Nonetheless, AHA is very likely to set some new mechanisms—possibly the opportunity for those appealing audit decisions to accept settlements based on the history of success in appeals.  Such a mechanism was previously crafted by HHS and extended to hospitals, but it did not succeed in markedly reducing the ALJ backlog.

    Stay tuned, and AOPA will keep you apprised as finally, the courts demand that HHS/CMS take seriously the statutory requirement that entitles a provider who is audited, to receive an ALJ decision within 90 days of filing the appeal.  The Court readily acknowledged that, “(T)he agency is also bound by statutorily mandated deadlines, of which it is in flagrant violation as to hundreds of thousands of appeals.”

    Read the memo from United States District Judge James E. Boasberg.

    CMS Releases the 2017 DMEPOS Fee Schedule

    The Centers for Medicare and Medicaid Services (CMS) has released the 2017 Medicare DMEPOS fee schedule which will be effective for Medicare claims with a date of service on or after January 1, 2017.  The 2017 Medicare fee schedule for orthotic and prosthetic services will be increased by 0.7% over 2016 rates. The 0.7% increase is a net reflection of the 1% increase in the Consumer Pricing Index for Urban Areas (CPI-U) from June 2015 through June 2016, combined with the annual Multi-Factor Productivity Adjustment (MFP) of -0.3%.

    The 0.7% increase in the O&P Medicare fee schedule for 2017 is relatively good news after the fee schedule was actually reduced by 0.4% in 2016.  Unfortunately, the 2% sequestration based reduction to all Medicare payments remains in effect (currently through 2025) meaning that Medicare fee for service payments will continue to be reduced by 2% due to sequestration.  While sequestration continues to impact Medicare reimbursement, it is not cumulative.  You will still receive 0.7% more for a service you provide in 2017 then you did in 2016 since the 2% sequestration reduction would be applied to both claims.

    Download the 2017 Medicare DMEPOS fee schedule from the CMS website.

    As always, AOPA maintains the most current Medicare fee schedule information and will be happy to provide it to AOPA members.

    Questions regarding the 2017 Medicare fee schedule may be directed to Joe McTernan at jmcternan@aopanet.org or Devon Bernard at dbernard@aopanet.org.

    OIG Releases 2017 Work Plan

    HHS OIG Releases 2017 Work Plan-Two Longstanding Objectives in Orthotics Remain; No Other/New Prosthetic or Orthotic Items Listed

    Each year, the HHS Inspector General releases its annual Work Plan, which lists the topics where the OIG believes there are significant potential items of fraud or other inappropriate or inefficient operations by HHS (including CMS and Medicare) that are costing the government money. This week, the OIG 2017 Work Plan was released.

    There are no NEW O&P items listed on the new OIG 2017 Work Plan. However, there are two significant orthotic items for scrutiny that have been part of the OIG Work Plan for the past few years still remain. The following items continue to be highlighted by the OIG:

    Orthotic Braces – Reasonableness of Medicare Payments Compared to Amounts Paid by Other Payers
    Since 2009, Medicare payments for orthotic braces, including back and knee, have more than doubled almost tripled for certain types of knee braces. We will determine the reasonableness of Medicare fee schedule amounts for orthotic braces. We will compare Medicare payments made for orthotic braces to amounts paid by non-Medicare payers, such as private insurance companies, to identify potentially wasteful spending. We will estimate the financial impact on Medicare and on beneficiaries of aligning the fee schedule for orthotic braces with those of non-Medicare payers. OAS: W-00-17-35756; various reviews Expected issue date: FY 2017

    Orthotic Braces – Supplier Compliance with Payment Requirements
    Medicare requires that suppliers’ claims for DMEPOS be “reasonable and necessary” (SSA § 1862(a)(1)(A)). Further, local coverage determinations issued by the four Medicare contractors that process DMEPOS claims include utilization guidelines and documentation requirements for orthotic braces. Prior OIG work indicated that some DMEPOS suppliers were billing for services that were medically unnecessary (e.g., beneficiaries receiving multiple braces and referring physician did not see the beneficiary) or were not documented in accordance with Medicare requirements. We will review Medicare Part B payments for orthotic braces to determine whether they were medically necessary and were supported in accordance with Medicare requirements. OAS: W-00-17-35749 Expected issue date: FY 2017

    These were the subject of an extensive memo to AOPA members last year. AOPA included comments about the OIG’s concerns about not being the lowest payer for orthotic bracing. This was accompanied by a memo written by health care consulant McGuire Woods.  Read AOPA’s comments. Read the McGuire Woods memo.

    Read the entire OIG 2017 Work Plan.

    How the New Trump Administration Will Impact The OIG Priorities and 2017 Work Plan
    It is worth noting that with the new Trump Administration we will almost certainly have a new HHS Secretary, and a new CMS Administrator. There is less certainly about whether there will also be a new HHS OIG, as there is some precedent for trying to keep OIG positions non-political. But there is also the chance that this 2017 OIG Work Plan evolves into something a bit different with the expected changes for health care foreseen for 2017.

    AOPA’s Post-Election Analysis

    GOP Runs the Table, Trump Wins Presidency, and Maintains Control of Both Senate and House

    In an election unprecedented in American history, Donald Trump defied the polls, conventional wisdom and notions of political correctness for a convincing win of the Presidency in the Electoral College, despite a roughly break even in the popular vote. What does it mean for orthotics and prosthetics, and health care more generally?

    It is clear that the Affordable Care Act is likely to be repealed. There will need to be a replacement, and it may have several consistent features, for example, no exclusions for pre-existing conditions and maintaining kids on parents’ coverage until age 26. But expect the medical device excise tax to be history, as will major subsidies, and any tax on uninsureds. Medicaid will likely be addressed by block grants to states to use as they deem appropriate. Similarly, expect a move toward vouchers in Medicare. We’ll have a new CMS leadership, and large amounts set aside for innovations, ACOs and such may go away.

    Beyond the Affordable Care Act, health care was not a major issue debated heavily in this election, so beyond these broad issues, what the Trump Administration’s health care will look like is not that clear. AOPA’s counsel, Alston & Bird, published a general overview, which included the following which we provide with attribution to our counsel’s authorship.

    PRESIDENT-ELECT TRUMP’S HEALTH CARE PROPOSALS

    The key issues include: health insurance coverage and costs; Medicaid; Medicare; opioids; prescription drugs; women’s reproductive health; mental health; and Zika funding. Almost any significant change below could face challenges in Congress. Below is an overview of President-Elect Trump’s proposals.

    Donald Trump

    Health insurance coverage and costs
    * Repeal ACA and eliminate individual mandate
    * Allow insurance to be sold across state lines
    * Allow taxpayers to deduct entire health premium
    * Allow people to enroll in tax-free Health Savings Accounts usable by all family members and inheritable without tax penalty
    * Require price transparency from all health care providers to enable individuals to shop for the best prices on medical procedures
    * Protect individuals from premium increases or exclusions due to the preexisting conditions
    * Enforce immigration laws and restrict visas to reduce healthcare costs
    * Work with states to establish high-risk pools to ensure access for individuals who have not maintained continuous coverage

    Medicaid
    * Move Medicaid to block grants for the states

    Medicare
    * Guarantee enrollees have an income-adjusted contribution toward a plan of their choice with catastrophic protection

    Opioids
    * Stop inflow of opioids
    * Invest in heroin addiction treatment

    Prescription drugs
    * Allow drug importation
    * Allow Medicare to negotiate drug prices
    * Allow abortion only to save the life of the woman or in cases of rape and incest; limit access to later term abortions; make the Hyde amendment permanent

    Women’s reproductive health
    * Defund Planned Parenthood

    Mental health
    * Promote reform of mental health programs and institutions to assist families in helping loved ones

    Zika funding
    * Provide funding for Zika

    In terms of specific impact on O&P, perhaps three comments are noteworthy: (1) the only Democratic candidate for the Senate who succeeded in defeating a seated Republican Senator is Senator-Elect Tammy Duckworth (D-IL), who as we all know is a double amputee Iraq war hero who has been a major champion for O&P; (2) President-Elect Trump has emphasized a commitment to improve care for Vets, and our guess is that could well improve the role for private sector contractors and lessen movement toward more O&P care by VA-employee prosthetists/orthotists; and (3) the threat for competitive bidding being errantly applied to O&P, and the strong reliance on data driven decisions and emphasis on quality and cost effectiveness of care are concepts largely embraced on both sides of the aisle, so we can expect the efforts as well as some battles around these to continue. There will almost certainly be a lame duck session of the old Congress, likely a short one with many remaining issues simply pushed forward to the new President and Congress. However, AOPA has laid a good bi-partisan foundation for possible action on issues around both S.829/H.R. 1530, the Medicare O&P Improvements Act, and the proposed LCD during that lame duck session, the timing and duration of the session permitting.

    As with any new administration, it will take time for Presidential cabinet and agency appointments to play out, as well as for new health-related Committees in the House and Senate to be settled-in short, it will take a while to determine who key players in the Executive branch and in the 115th Congress will be. AOPA will continue to be a strong advocate for O&P professionals and their patients. Our 2017 AOPA Policy Forum is slated for May 2017, with tentative, but most likely dates being May 23-25. 2017 promises to usher in a brave new world in Washington-mark your calendars for the AOPA Policy Forum, and plan to be part of it!

    CMS Releases 2017 HCPCS Codes

     The Centers for Medicare and Medicaid Services (CMS) has released the new HCPCS codes for 2017, and there were only a few minor changes.

    The biggest change was the deletion of the temporary K codes (K0901 & K0902), which became effective on October 1, 2014, to describe off the shelf (OTS) versions of custom fitted knee orthoses described by L1843 and L1845, and their subsequent crosswalk to new permanent L codes (L1851 & L1852).

    Below is a complete breakdown of the code changes which will be effective for claims with a date of service on or after January 1, 2017.

     New Codes 

    Code Descriptor
    A4467 Belt, strap, sleeve, garment, or covering, any type
    A9285 Inversion/eversion correction device
    L1851 Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf
    L1852 Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

    Changes in Code Descriptors 

    Code New Descriptor Old Descriptor
    L1906 Ankle foot orthosis, multiligamentous ankle support, prefabricated, off-the-shelf AFO, multiligamentous ankle support, prefabricated, off-the-shelf

    Deleted Codes 

    Code Descriptor
    A4466 Garment, belt, sleeve or other covering, elastic or similar stretchable material, any type, each
    K0901 Knee orthosis (ko), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf
    K0902 Knee orthosis (ko), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

     

    AOPA‘s Coding and Reimbursement Committee will review the list of changes and provide appropriate comments to CMS.

    As a reminder registration is still open for the December 14, 2016 AOPAversity webinar, New Codes & What Lies Ahead for 2017, which will focus on the changes to the HCPCS codes and any other upcoming Medicare changes which may impact your business in 2017.

    Questions regarding the code changes may be directed to Joe McTernan at jmcternan@AOPAnet.org , or Devon Bernard at dbernard@AOPAnet.org.

     

    CMS Announces New RAC Contractors

    As we reported in July, the Centers for Medicare and Medicaid Services (CMS), placed all the activities of four existing Recovery Audit Contractors (RAC) contractors on hiatus as a result of the upcoming award of new RAC contracts.This hiatus was to allow for a smooth transition to the new RAC contractors, including the single, national RAC contractor that will focus on claims for DMEPOS, Home Health, and Hospice services when the new contracts are awarded.

    On Monday, October 31 CMS announced the awarding of the new contracts for the next phase of the RACs. The new single RAC for DMEPOS, Home Health and Hospice is Performant Recovery, Inc. Performant Recovery recently acted as the RAC for Jurisdiction A.

    CMS is confident that the awarding of the new RAC contracts “will continue to reduce provider burden, enhance program oversight, and increase transparency in the program.” It is not known when the new contracts will take effect and when Performant will begin its duties as the single RAC for O&P claims.

    AOPA will keep you posted when more information is made available.

    Noridian Prepayment Review Results

    Noridian, the Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor (DME MAC), recently released their quarterly results of its review for claims involving the HCPCS codes L1832, L1843, L0648, L0650 and L4361.

    Between April 2016 and July 2016 Noridian reviewed 161 claims involving the L1832 and 152 claims were denied; resulting in a 99% error/denial rate. The previous denial/error rate was 100%.  The review of claims involving the L1843 had a denial/error rate of 98%; 111 of 112 claims were denied.

    The top four denial reasons were listed as:

    • Documentation submitted didn’t justify the need for a custom fitted brace
    • Documentation did not support the presence of knee instability or that the beneficiary is ambulatory
    • Documentation was not submitted in response to the Additional Documentation Request
    • Invalid/Incomplete/Missing proof of delivery

    Noridian released their quarterly results of its prepayment review for L0648 and L0650. Between April 2016 and July 2016 Noridian reviewed 275 claims involving the L0648 and 186 claims were denied; resulting in a 64% error/denial rate. The previous quarter’s denial rate (January-April) was 74%.  The review of claims involving the L0650 had a denial/error rate of 83%; 425 of 512 reviewed claims were denied.  The previous quarter’s denial rate (January-April) was 82%.

    Some of the top denial reasons listed included:

    • Invalid/Missing/Incomplete detailed written orders
    • Documentation was not submitted in response to the Additional Documentation Request
    • Invalid/Incomplete/Missing proof of delivery

    Noridian also released their quarterly results for claims involving HCPCS code L4361 (walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf). Between April 2016 and July 2016 Noridian reviewed 378 claims or the L4361, and 270 were denied. This resulted in a claim denial/error rate of 73%.

    The top four denial reasons were listed as:

    • Invalid/Missing/Incomplete detailed written orders
    • Documentation was not submitted in response to the Additional Documentation Request
    • Invalid/Incomplete/Missing proof of delivery
    • Documentation didn’t support basic coverage criteria (patient was ambulatory, patient had a weakness/deformity of the ankle, potential to benefit, etc.)

    Based on the high denial/error rates Noridian will continue with the prepayment review for all of those codes.

    Questions? Contact Devon Bernard at dbernard@AOPAnet.org or Joe McTernan at jmcternan@AOPAnet.org.