Month: May 2017

On May 4, 2017, CGS Administrators, LLC, the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for Jurisdiction C, announced the initiation of a widespread pre-payment review for HCPCS code L5856-Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type.  L5856 is used as an addition code to prosthetic knee components that incorporate the use of a microprocessor to control the knee during both swing and stance phase of the gait cycle.

CGS announced that the pre-payment review will begin on or around June 15, 2017 and suggested that providers review the current LCD and Policy Article for lower limb prostheses and to reference the CGS documentation checklist for lower limb prostheses that may be accessed here.

While the CGS documentation checklist is a useful tool, it does not contain any specific information regarding coverage requirements for microprocessor controlled prostheses.  AOPA members are encouraged to work with their physician partners to ensure that documentation regarding the need for a microprocessor controlled prosthetic knee is present in the patient’s medical record.  The documentation must address the need for a microprocessor knee over a conventional prosthetic knee as well as support the need for K3 or higher functional level components.

CGS did not indicate how many claims will be affected by the widespread review but did indicate that the pre-payment review will occur across all provider groups who submit claims including L5856.

AOPA will follow this issue very closely and provide continued support to AOPA members regarding this newly announced pre-payment review.  Questions regarding this issue may be directed to Joe McTernan at jmcternan@aopanet.org or Devon Bernard at dbernard@aopanet.org.

This afternoon, the House voted to enact the American Health Care Act (AHCA). This is the initial legislative step in a process intended to eliminate major portions of the Affordable Care Act. Most folks recognize that this was the second attempt on this bill, after it came up short a few weeks before. There were significant revisions between today’s legislative language and the prior one. The MacArthur amendment establishes a permissible state waiver, allowing states to: increase the age rating ratio above the 5:1 ratio; specify the essential health benefits that are required to be covered; and implements a health status rating for states operating a risk mitigation program or participating in a Federal Invisible Risk Sharing Program. The Upton amendment provides an additional $8 billion over five years to offset or reduce premiums or other out-of-pocket costs for certain individuals with pre-existing conditions.

One unprecedented characteristic of today’s vote was that it was enacted without a CBO score being rendered on this revised bill, as virtually no Medicare, healthcare or other major policy legislation is enacted without an assessment of costs by CBO, and if there is a cost identified by CBO, Congress also identifies one or more steps to create offsetting savings equivalent to any increased costs attributed to the bill by CBO. For instance, the Affordable Care Act followed the details of a CBO score that identified costs and offsetting savings amounting to $750 billion over ten years, and many issues O&P has faced, e.g., RAC audits, find their genesis in those CBO-scored offsetting “savings.” While the American Health Care Act was enacted without any announcement from CBO, it is likely that this version shares the likely outcome identified by CBO on the prior version that AHCA’s enactment would result in a reduction by 24 million the number of Americans who have health care insurance coverage.

The House vote is a first step-it will not alone kill the ACA. As noted, the House bill is an initial step, and with the House having acted to repeal the ACA so many times previously, the body most opposed to the ACA has started the process of repeal. Now, the real action will be in the Senate. The plan is to move the American Health Care Act in the Senate via the budget reconciliation process-that means filibuster is avoided, but also this process is limited to items that have a demonstrated federal budget financial aspect. Assuming that most, if not all Democrats in the Senate will be inclined to oppose this bill, it is important to note that there are several Republicans, e.g., Sens. Collins, Murkowski, and one of our AOPA Policy Forum speakers, Sen. Cassidy, who have some significant reservations about the bill passed by the House. In the Senate, we do not expect action in the short term, nor do we expect them to consider the bill as passed in the House. We believe the Senate is likely to move to revise the bill, but they will move at Senate pace.

Most polling has shown very significant public opposition to the American Health Care Act’s provisions. Also, most major health organizations, groups like the American Medical Association, the American Hospital Association, and the American Association of Retired Persons oppose the AHCA.

So, in conclusion, the battle over the ACA has been re-engaged via the vote today in the House, and the House continues to take a fairly dramatic role on the Affordable Care Act. Ironically, in 2009, Democrats cobbled together 220 votes with just one GOP vote (most folks forget Rep. Joseph Cao, R-LA). Today, GOP cobbled together 217 GOP votes to rebut much of it. Many argue that there ought to be a better way for our patients.

Obviously, we will continue to watch closely actions relating to major repeal or revisions to the Affordable Care Act. Certainly discussions in recent weeks relating to reducing: (a) the number of insured Americans; (b) certainty of national standards for essential health benefits; and (c) pre-existing conditions will be important to our patients, and to those serving them at all levels in O&P.