O&P stakeholders work relationships

WASHINGTON – Stakeholders commend CMS for improvements to the recently implemented prior authorization program for five orthosis codes, but they continue to press the agency to address concerns related to direct-to-consumer shipping of certain devices.  

While a nearly year-old PA program for lower limb prosthetics has been successful, stakeholders feared that the two-day turnaround for approval for orthotics would delay care, says Joe McTernan, director of coding and reimbursement services, education, and programming for the American Orthotic & Prosthetic Association. 

“There were some nuances that didn’t concern us on the prosthetic side that concerned us on the orthotic side, and it was really about timely delivery and access to care,” he said of L0648, L0650, L1832, L1833 and L1851 being added to the program. “A patient comes into the emergency room with a fracture that needs stabilization in order to safely leave that location. We heard a lot of concern from our members about, how are we going to address this?” 

In an FAQ published just before the PA program went into effect in four states on April 13, CMS stated that for patients who need orthotic braces earlier than the two-day expedited timeframe, providers can bill claims with the ST modifier so they will not go through the PA process. Instead, they will be subject to a 100% pre-pay review. 

McTernan credited the relationships AOPA has been building with CMS and the DME MACs for the modifications to the program. 

“We want to be part of the solution, so when there is an issue that comes up, that trust is there and the value is there with the right folks,” he said. 

Relationship building is also how stakeholders are forging ahead on other O&P initiatives, in particular efforts to combat fraud and abuse. The O&P Alliance, which also includes the Academy of Orthotists and Prosthetists, ABC, BOC and National Association for the Advancement of Orthotic and Prosthetic Patient Care, recently issued a statement opposing direct-to-consumer delivery of custom orthotics and prosthetics.  

“We encourage development in technology to increase access to devices, but they still need health care,” said Ashlie White, director of health policy and strategic alliances for AOPA. “If a patient purchases a device off the internet and walks into an O&P facility and asks for help, that facility from a liability and reimbursement perspective is not able to help that patient.” 

Legislation in both the House of Representatives and the Senate seeks to address those concerns, by, among other things, restoring the term “minimal self-adjustment” to more clearly define off-the-shelf orthoses; and prohibiting the practice of “drop shipping” custom orthoses and prostheses. The legislation, the Medicare Orthotics and Prosthetics Patient-Centered Care Act, will take center stage at AOPA’s 2022 Policy Forum, May 17-18 at the Hilton Crystal City in Arlington, Va. 

“We’re realistic about how things are getting done in Congress and are encouraged by the traction we’ve gained,” said White. “At this point, the questions are will there be a Medicare bill that moves by the end of the year and if so, can we get part or all of our legislation added to it. We are looking for opportunities and remain hopeful.”