Back braces: AOPA says data needed to paint detailed picture

WASHINGTON - An Office of Inspector General (OIG) report that says CMS pays too much for certain back braces misses the mark on some key points, say O&P stakeholders.

The Dec. 17 report says that from 2008 to 2011, claims for L0631 back orthoses more than doubled, from $36 million to more than $96 million. With the devices offered in a variety of settings, from home medical equipment suppliers to physician offices, the reasons for the increase could vary, says Tom Fise.

“Has the volume been uniform across the board in the last couple of years or has it been concentrated in one or two areas?” said Fise, executive director of the American Orthotic & Prosthetic Association (AOPA). “If it's going up the same everywhere, maybe this is just a device that everybody has found important to use. If it's going up disproportionately in one or two settings, then that may tell us something different.”

The report also says that the $96 million paid out by Medicare in 2011 is nearly four times what providers paid to acquire the devices. Between July 1, 2010, and June 30, 2011, the average Medicare allowable for the orthoses was $919; the average supplier acquisition cost was $191, according to the report.

The OIG recommended that CMS lower the fee schedule for L0631 by using supplier acquisition costs, and include the product in a future round of competitive bidding. However, the description for the code includes fitting and adjustment services. For any orthotic device to be included in competitive bidding, it must be classified as “off-the-shelf,” meaning the patient can use it with “minimal self-adjustment,” says Fise.

“If a device requires clinical care by the certified orthotist, by the OT, by the physician, or by anybody else, then it doesn't meet the definition,” he said.

CMS in February 2012 included L0631 in a proposed list of off-the-shelf orthotics that could eventually be included in competitive bidding. CMS is still in the process of finalizing the list.