O&P market keeps marching forward

Facing regulatory challenges and guided by optimistic market forecasts, orthotics and prosthetics providers are forging ahead to overcome obstacles and strengthen the category. 

Between prior authorization requirements from CMS’ Final Rule CMS-1713 and moving beyond Operation Brace Yourself, O&P providers face higher standards while focusing on rebuilding trust with clients. Adam Miller, president of Waterloo, Iowa-based VGM’s Orthotic and Prosthetic Group of America, says other challenges exist as well. 

“Much like other types of businesses, having enough skilled staffing, supply chain issues and reimbursement rates from payer sources continue to be challenges for the O&P profession,” he said. “Being involved in state and federal advocacy is more important than ever to present a clear and unified mission for our industry.” 

Yet O&P market projections call for solid growth through 2030, estimating a nearly 4% growth rate by the end of the decade. Key market drivers, according to a report from global firm Precedence Research, are body ailments related to an aging population, including osteoarthritis and osteoporosis. Sports-related injuries are also driving the expected market upsurge, the report said. 

“As people seek alternatives to surgical deformity repair and pain management, the use of orthotic devices will be used all around the world,” report authors stated. “Furthermore, the advancements in the prosthetics and orthotics market are making orthotic devices more affordable and accessible. Thus, the rise in demand for orthotic devices is boosting the growth of prosthetics and orthotics market during the forecast period.” 

Beyond ‘Brace Yourself’ 

Some O&P providers got snared in a widespread federal investigation into Medicare fraud in 2019 that included billing abuse in several health industry categories. With reputations tarnished and negative public perceptions continuing from “Operation Brace Yourself,” the O&P profession has work to do in repairing its image. 

Matthew Gruskin, chief operating officer for the Owings Mills, Md.-based Board of Certification/Accreditation, says moving ahead from the scandal relies on rebuilding patient trust and adhering to high standards. 

“A great way to continue maintaining this trust is to demonstrate accountability and caring for your patients,” Gruskin said. “A positive customer experience contributes to a positive reputation and a renewed appreciation for the long-term value of DMEPOS providers.” 

It is also important for providers to demonstrate they are following best practices and staying compliant, Gruskin continued.  

“Accreditation publicly demonstrates compliance and providers can also perform regular self-audits prior to an accreditation survey to help ensure their business continues to meet CMS standards,” he said. “Providers should utilize their accrediting organization as a resource to stay up to date on regulatory changes and receive guidance on incorporating new, improved processes to help their business succeed.” 

Miller points to H.R. 1990/S. 2556, known as the Medicare O&P Patient-Centered Act, as a measure that can rectify the situation that led to the Medicare investigation. 

The legislation requires providers to meet certain standards with respect to licensure and accreditation, have physical facilities and appropriate liability insurance. Furthermore, it would prohibit payment under Medicare for certain prosthetics and orthotics that are drop-shipped to patients who have not received corresponding patient care from a health care practitioner. 

“The vast majority of O&P practices do business the right way for the right reasons – to provide expert care to their patients so their patients can live without limitations,” Miller said. 

Regulatory headwinds 

Another challenge for providers is complying with CMS’s Final Rule CMS-1713 that establishes a prior authorization process as a condition of payment for items that are frequently subject to unnecessary utilization. This means that products on the Required Prior Authorization List and on the Required Face-to-Face Encounter and Written Order Prior to Delivery List in the final rule must be submitted to CMS for approval before delivery to the patient, or the provider will not be reimbursed by CMS. These lists were updated in 2022. 

“To overcome this challenge, providers should carefully follow local coverage determinations and review the CMS website and Master List of DMEPOS Items to determine which products may require the prior authorization process,” Gruskin said.  

Providers also need to focus on what they can control and impact, he said, alluding to a model called the Quadruple Aim framework.  

“Balancing the components of the Quadruple Aim framework is a good place to start overcoming this challenge, because it focuses on improving patient outcomes, improving the patient and clinician experience while lowering costs for care,” Gruskin said. 

The tech front 

Miller believes technology and innovation are at the forefront of O&P and “is perhaps more apparent than in any other healthcare related vertical,” he said. Advancements in robotic limbs and 3D printing, systems that track outcomes in real time and software that manages every aspect of a clinic’s business define a new horizon for the category. 

“Practitioners are able to offer services and care that was not thought possible even 10 short years ago,” Miller said. “It is definitely an exciting time from an innovation standpoint and I am anxious to see what the next decade brings.”