Year: 2020

Like all of you, the American Orthotic and Prosthetic Association (AOPA) leadership is closely following the coronavirus disease (COVID-19). As you have likely heard, we have made the tough decision to cancel several of our upcoming events in light of it.

We know that these are difficult and uncertain times for you and your patients. Please know, the Board and staff are here to support you so that you can continue to provide quality care to your patients.

As the situation evolves daily, we encourage you to follow the guidance being issued from the Centers for Disease Control and Prevention (CDC), the World Health Organization, and your local, state, and the federal governments. Specifically, the CDC has this webpage with resources and guidance for healthcare facilities. AOPA will continue to monitor the situation and provide guidance as appropriate.

Thank you for all you do for your patients and the O&P profession.  As always do not hesitate to contact any of the AOPA staff with questions, concerns, or needs.  

Stay safe and well.

Yesterday, March 11, AOPA participated in a Medicare Open Door Forum call that provided sub-regulatory guidance on the upcoming implementation of Medicare prior authorization for six lower limb prosthesis HCPCS codes.  The call was hosted by the Centers for Medicare and Medicaid Services (CMS) and was led by Amy Cinquegrani and Dr. Scott Lawrence of the Medicare Division of Payment Methods and Strategies.  The four DME MAC Medical Directors also participated in the call and the question and answer period that followed it.  The presentation that was used as an outline was published in advance by CMS and may be accessed here. For additional information on Medicare prior authorization read AOPA’s initial announcement from February 11.

During the call, AOPA had the opportunity to request clarification regarding several issues that CMS had previously indicated would be addressed through sub-regulatory guidance.  New information received during the call included the following:

• DME MACs will issue decisions on initial prior authorization requests within 10 business days of receipt of the request.
• DME MACs will issue decisions on prior authorization resubmissions within 10 business days of receipt of the request (previous Medicare prior authorization programs allowed 20 business days for prior authorization resubmissions).
• DME MACs will issue decisions on expedited prior authorization requests within two business days of receipt.  In order to be approved, an expedited request must show that the beneficiary’s life or health is in immediate danger.
• Prior authorization requests may be submitted through multiple channels including electronic submission, submission through the DME MAC claim portal, by fax, and by mail.
• For the four states (PA, MI, TX, CA) scheduled for implementation of prior authorization for dates of service on or after May 11, 2020, the DME MACs will begin accepting prior authorization requests on April 27, 2020.  For national implementation for dates of service on or after October 8, 2020, the DME MACs will begin accepting prior authorization requests on September 24, 2020.
• HCPCS codes that receive provisional affirmation will not be subject to additional medical review except for random CERT review and UPIC (fraud and abuse) review.  This only applies to the six HCPCS codes subject to Medicare prior authorization.
• DME MACs will provide education when prior authorization requests are denied, allowing providers to correct errors and facilitate re-submission.
• CMS and DME MACs will closely monitor efforts to adhere to established timeframes for initial decisions and re-submissions.
• Prior authorization requests will be subject to existing Medicare policy governing coverage of lower limb prostheses.  No changes are being made to the LCD or Policy Article as a result of prior authorization.

AOPA continues to be encouraged by the communication efforts of CMS and the DME MACs regarding the implementation of Medicare prior authorization.  While some uncertainty remains, AOPA is confident that Medicare prior authorization can be beneficial to Medicare beneficiaries, providers, and the Medicare program.

AOPA will continue to communicate information regarding Medicare prior authorization to our members and will be developing educational resources that will help AOPA members to better understand the program and contribute to its success.

Questions regarding Medicare prior authorization or the CMS Open Door Forum call may be directed to Joe McTernan at jmcternan@AOPAnet.org or Devon Bernard at dbernard@AOPAnet.org.

On February 11, we notified you that the Centers for Medicare and Medicaid Services (CMS) had announced that six lower limb prosthetic codes will be added to the codes that require Medicare prior authorization as a condition of payment. The full notification can be found here.

AOPA has continued to monitor communications from CMS and the DME MAC contractors regarding the Medicare prior authorization process. To that end, the CMS Center for Program Integrity will hold a Special Open Door Forum – Prior Authorization Process for Certain Durable Medical Equipment Prosthetics, Orthotics and Supplies Items: Inclusion of Lower Limb Prosthetics in Prior Authorization on Wednesday, March 11 from 2 – 3pm ET. During this conference call, they will outline the process for submitting a prior authorization request to the designated DME MAC, the timeframes for the DME MAC to render their prior authorization decisions, and the process for subsequent claim submissions. Participants will be encouraged to submit questions or provide feedback.

AOPA will attend and provide updates to membership. If you want to attend, information on how to participate is available here.

AOPA remains encouraged by CMS’ transparency regarding prior authorization and will continue closely monitor developments and provide updates to the membership. Additionally, look for information on education AOPA will be providing to members regarding the prior authorization process.

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

On Friday, February 7, the Centers for Medicare and Medicaid Services (CMS) announced that six lower limb prosthetic codes will be added to the codes that require Medicare prior authorization as a condition of payment. The official announcement was published today, February 11 in the Federal Register.  

AOPA has actively communicated concerns about Medicare prior authorization and its potential to cause unnecessary delays in timely and efficient O&P care with CMS, through the submission of formal comments and during in-person meetings with CMS officials.  In response, prior to the release of this Federal Register publication, AOPA received an e-mail communication from a high-ranking CMS official that addressed its concerns. Specifically, the e-mail communication stated the following:

• CMS does not intend to significantly expand the number of lower limb prostheses subject to prior authorization in the future.
• CMS understands the need for timeliness in making prior authorization decisions.
• DME MACs will provide education to providers when prior authorization requests are not initially approved.
• Affirmative prior authorization decisions will guarantee payment and reduce likelihood of audits down the road.

AOPA is encouraged by CMS’ efforts to address its previously stated concern regarding prior authorization and will closely monitor the prior authorization process to ensure that it does not lead to unnecessary delays in delivery of clinically appropriate prosthetic care to Medicare beneficiaries.   The initial implementation of prior authorization for the six codes, scheduled for May 2020, will occur on a very limited basis in one state in each of the four DME MAC jurisdictions (Pennsylvania, Michigan, Texas, and California). Nationwide implementation is scheduled for late 2020. The six codes that will require Medicare prior authorization are:  

The selected codes represent three microprocessor based prosthetic knees, a microprocessor based prosthetic foot, and two functional level 3 prosthetic feet.  

AOPA will continue to monitor communications from CMS and the DME MAC contractors regarding the Medicare prior authorization process and will provide additional education to AOPA members as more details regarding the prior authorization process are released.  

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

On January 29, 2020, AOPA staff participated in a CMS listening session that was designed to receive provider feedback on the operational performance of Medicare Administrative Contractors (MACs).  The session was introduced by CMS Administrator Seema Verma and was moderated by Larry Young, the Director of the CMS Medicare Contractor Management Group.

The 60-minute session provided a brief background on the roles and responsibilities of the MACs, a discussion of general MAC performance based on CMS metrics, and then was opened to allow participants to provide feedback on opportunities for the MACs to improve their performance and enhance their interaction with providers. 

AOPA submitted written comments in advance of the listening session that encouraged CMS to fully implement the qualified provider provisions outlined in section 427 of the Benefits Improvement Act of 2000 and allow the DME MACs to incorporate those provisions into it claims processing activities.  AOPA’s comments also encouraged CMS to provide clear instructions to the DME MACs regarding the inclusion of orthotist’s and prosthetist’s clinical notes as part of the patient’s medical record for medical review purposes.

AOPA continues to support open dialogue with CMS and the DME MACs with the goal of achieving fair and equitable treatment of O&P providers and ensuring that Medicare beneficiaries continue to have access to high quality, clinically appropriate orthotic and prosthetic care.

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

Yesterday, at the request of Virginia Orthotic & Prosthetic Association, AOPA staff joined the Amputee Coalition to testify in front of the Labor and Commerce subcommittee of the Virginia House of Delegates in support of HB 503. This bill (first introduced in 2019) would mandate health insurance coverage for mechanical, bionic prosthetics that have a Medicare code under all Virginia state regulated health plans.

AOPA testified that, “The existing Insurance Fairness law has made it possible for Virginians living with limb loss and limb difference to receive care that would have otherwise been arbitrarily denied or capped, but it does not extend this guarantee of coverage to the most vulnerable individuals in our community. It also fails to secure access for patients to the most medically appropriate prosthetic devices for the restoration of mobility. Passage of this Bill will rectify these shortcomings.”

Read the full AOPA testimony.

Watch the AOPA testimony.

Following the hearing the legislation was recommended to be continued to the next session, upon the recommendation that the Health Insurance Reform Commission (HIRC) continue to review the impacts of the Bill, per its mandate.

The Senate companion bill, SB 382 passed out of the subcommittee and is now on the docket in the Senate Finance Committee.  

Questions? Contact Justin Beland AOPA’s Director of Government Affairs at jbeland@AOPAnet.org.

Thanks in large part to your efforts, the American Orthotic and Prosthetic Association (AOPA) secured several legislative victories in 2019, positioning us to achieve even more success in the second session of the 116^th Congress, which convenes on January 7. Our victories included:

• In May, Congress introduced the Wounded Warrior Workforce Enhancement Act which would authorize $5 million per year for three years to provide limited, one-time competitive grants to qualified universities to create or expand accredited advanced education programs in prosthetics and orthotics. AOPA has been working closely with both the Veteran’s Affairs Committee and Armed Services Committee to speed passage of the bill in 2020.
• Related to workforce shortages, AOPA worked with the Military Construction and Veteran’s Affairs Appropriations subcommittee to add language to their FY2020 spending bill which “directs the VA to work with outside industry experts to survey and examine the latest data available on the current extent of orthotics and prosthetics care provided outside of VA facilities and provide projections on requirements over the next decade based on overall population growth among veterans with orthotics and prosthetics needs.” The subcommittee has requested a report to both the House and Senate by June, and AOPA is working with VA staff to provide input to the report.
• AOPA secured a bipartisan letter, led by Reps. Elaine Luria (D-VA), Tim Walberg (R-MI), Greg Steube (R-FL), and Brad Wenstrup (R-OH), to the Chair and Ranking Member of the House Veteran’s Affairs Appropriations subcommittee, urging the subcommittee “to include language to let veterans with limb loss continue to choose to receive their care from the provider who best meets their needs.” In the final bill language, the subcommittee noted that the VA is “expected to ensure veterans continue to receive the prosthetics services that best meet their needs,” and will continue to work with the VA to ensure veteran’s choice of where they receive their care.
• AOPA worked with Congress to secure a 50 percent increase (to $15 million) in the Department of Defense’s funding bill for the Congressionally Directed Medical Research Program (CDMRP) to advance research in prosthetic and orthotic outcomes, and priorities for research to fill those gaps. AOPA will work closely with CDMRP to ensure they’re receiving high quality grant proposals and funding the best available research opportunities.
• On November 22, the House introduced H.R. 5262, the Medicare Orthotics and Prosthetics Patient-Centered Care Act. While the bill enjoys broad bipartisan support, it’s imperative that we add as many cosponsors as possible, to illustrate the importance of the bill to legislators. To that end and with your help, nearly 1,100 advocates wrote to their members of Congress in support of the bill. A high priority for AOPA, this bill would:
  • Restore congressional intent by revising the overly expansive regulatory interpretation of the meaning of “off-the-shelf” (OTS) orthotics to clarify that competitive bidding may only apply to orthoses that require minimal self-adjustment by patients themselves, not the patient’s caregiver or a supplier.
  • Distinguish the clinical, service-oriented nature in which O&P is provided from the commodity-based nature of the durable medical equipment (DME) benefit. Orthotics and prosthetics care include a patient care component that is decidedly more in-depth and personal than simply supplying DME. Most orthotic and prosthetic devices are custom fabricated or custom fit and require the expertise of an orthotist or prosthetist who receive Master of Science degrees and residence training before becoming certified practitioners.
  • Reduce the likelihood of waste, fraud, and abuse in the Medicare program by prohibiting the practice of “drop shipping” (shipping an orthoses or prostheses to a beneficiary without first receiving direct patient care from a trained, certified or licensed health care practitioner) of orthotic braces that are not truly “off-the-shelf” (i.e., subject to minimal self-adjustment by the patient him- or herself).

So, what next? Continue to stay tuned for additional action you can take on the two pieces of legislation as well on other issues. Plan to attend the Policy Forum, May 5-6 in Washington DC. It is our opportunity to have our voices heard.

Thank you for your efforts in 2019, for continuing to advocate for the profession and its patients. Together we will further improve the lives of those living with limb loss and limb impairment.

If you have any questions, contact Justin Beland, AOPA Director of Government Affairs at jbeland@AOPAnet.org.

As part of their overall effort to reduce provider burden, the Centers for Medicare and Medicaid Services (CMS) recently announced a significant change to the requirements for physician orders for Durable Medical Equipment, Orthotics, Prosthetics, and Supplies (DMEPOS).  The change is effective for claims with a date of service on or after January 1, 2020 and eliminates the need for an initial/dispensing order for Medicare DMEPOS services. 

Going forward, Medicare claims will only require a “standard written order” (SWO) which must be received prior to claim submission and contain essentially the same elements as the traditional “detailed written order” that has been part of the longstanding Medicare requirements for compliant DMEPOS claims.  Required elements of the new SWO include the following:

• Beneficiary name or Medicare Beneficiary Identifier (MBI)
• Order date
• General description of the item
  • Can be either a general description, a HCPCS code, a HCPCS code narrative, or a brand name/model number
  • All separately billable features, additions, options, or accessories must be listed separately on the SWO
  • All separately billable supplies must be listed separately on the SWO
• Quantity to be dispensed, if applicable
• Treating/Ordering practitioner’s name or NPI
• Treating/Ordering practitioner’s signature

While initial/dispensing orders are no longer required for services to be reimbursed, medical records must continue to support the medical need for O&P services that are provided.  It is important to remember that medical need must clearly be established prior to the provision of O&P care.  O&P providers should confirm that adequate documentation of medical need is well documented before providing care to Medicare beneficiaries.  It is also important to remember that for any claims with a date of service prior to January 1, 2020, the former rules remain in effect and, in most cases, an initial/dispensing order and a detailed written order must be received in order to maintain compliance with Medicare regulations.

AOPA believes the changes in order requirements will significantly reduce instances of unnecessary claim denials and supports the recently announced change.  CMS efforts to reduce unnecessary administrative burdens on legitimate providers will allow providers to focus on providing efficient, clinically appropriate care to Medicare beneficiaries without getting caught up in unnecessary and unreasonable administrative requirements.

AOPA will continue to pursue opportunities to work collaboratively with CMS and other agencies to ensure that Medicare beneficiaries continue to have access to high quality, clinically appropriate O&P care delivered by properly qualified and credentialed O&P providers.