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    • Month: December 2016

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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

    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.