Two-thirds of O&P payments go to unlicensed providers, report says

WASHINGTON - When it comes to improper payments for orthotics and prosthetic (O&P) services, CMS is going after the wrong guy, according to a new report.

Instead of focusing its attention on reducing the number of improper payments going to unlicensed providers, CMS has “engaged in an overkill regulatory assault on legitimate licensed providers,” states a press release from the American Orthotic and Prosthetic Association (AOPA) hailing the report.

Two-thirds of the $3.62 billion that CMS paid between 2007-11 for O&P services for Medicare beneficiaries went to providers that did not meet licensure and accreditation requirements, found the report's author, Allen Dobson of Dobson DaVanzo & Associations and a former director of research at CMS's predecessor, the Health Care Financing Agency.

“The data from 2007 to 2011 show that there has not been any significant change by CMS to eliminate payments to unlicensed providers in O&P licensure states,” he said. “Specifically, only a small reduction in the proportion of payments to non-certified O&P personnel has been evidenced since 2009. Our analytic results are consistent with the results of a third-party independent survey that confirmed that non-certified providers are continuing to provide O&P services to Medicare beneficiaries as recently as in 2013.”

Instead of chasing illegitimate providers, the report and AOPA argue, CMS has launched a number of initiatives that would minimize the role of legitimate providers, including a controversial electronic clinical template that would shift documentation responsibilities to physicians.

AOPA supports efforts by Reps. Glenn Thompson, R-Pa., and Mike Thompson, D-Calif., to introduce legislation that would address the problem of fraud and abuse in O&P by limiting payments to providers with proven licensure and standards of training and experience.

“Allowing non-certified personnel to provide these services, especially in states with licensure, could lead to fraud and abuse in O&P services, as well as expose patients who received these services to inappropriate or substandard care,” the report states. “Therefore, shifting payment to only certified providers could result in better care for beneficiaries and lower Medicare payments.”