OPIE Con 2018

Last week marked our sixth OPIE Con, a Futura and OPIE Software user conference and training event.  Over 200 attendees, sponsors, and staff convened at the Grand Hyatt Tampa Bay from May 3-5th.  The 2018 event featured new content, revamped tracks, and new speakers.  At OPIE Con there is a little something for everyone, and the education provided is unlike anything else in the O&P profession. Connecting and collaborating is another big part of OPIE Con.

Valerie Vastola & Darren Donnelly

From icebreakers to group activities during the morning keynote, to ending the day with a fun reception – conference goers are never bored and walk away having built relationships with colleagues that can help them as they move forward in their offices.Each morning after the keynote speech, attendees break off into their specific educational track – Office Management or Clinical Management.  The three day program includes numerous breakout sessions that cover topics from clinical documentation and change management to the who, what when, where and why of effective WIP meetings.  Here’s a taste of what one of our many OPIE Con sessions cover:

Valerie Vastola, Administrative Trainer, walked attendees through how to run a data driven staff meeting that ensures your team is achieving daily tasks and goals.  Doing this small act each week helps to predict and prevent problems that may arise in your office.  Here are some basics that Valerie provided during her sessions:


How Do Weekly WIP Meetings Help my Patients and my Business?

  • Weekly staff meetings will ensure you are getting the most out of your software program
  • You will rule out problems that may occur and provide better patient care
  • Avoid chaos later during audits
  • You will ensure open and honest communication between staff members
  • Builds trust, camaraderie and growth for the company and team
  • Weekly WIP meetings are critical to the successful management of an O&P office.

When, Where and Who?

When should we have the meeting?

  • The meetings should be held weekly
  • Pick a day and time that will work for all staff
  • Keep the day and time each week and don’t change it
  • Enter a recurring appointment in the schedule for all practitioners
Where should this take place?
  • Anywhere in your office that can fit your team
  • Add a virtual option if you have staff spread across multiple offices to ensure everyone feels included

Who should attend? 

Everyone – Office Manager, Practitioners, Clerical Staff, Technician(s)


      What do we discuss?
  • Have an agenda
  • Follow the same agenda week to week
  • Pick one person to run the meeting
  • Pick one person to document the meeting (minutes)
  • Topics of discussion – deliveries, patient cases, fabrication issues, product delays, in-services, policy changes, staff vacations, etc.
What should we bring to the meeting?
  • System reports/updates
  • Work In progress/WIP (or access to electronic WIP)
  • Fab tracking/status and issues
  • Patient prescriptions/What is in the pipeline
  • Visits/deliveries
  • Practitioner schedules- What is scheduled next 10-14 days
  • Any topics that relate to patient care
  • Industry updates and product changes
  • An open mind and a positive attitude

“OPIE Con is a great 3-day immersion course that encourages a community atmosphere in the O&P world. I have met so many great people at these conferences, people who have helped me with workday issues and brainstormed simpler processes to benefit my facility. Paul has done an amazing job uniting a community together and creating a well-functioning program.”

–  OPIE Con Attendee, Samantha Case from Seacoast O&P



Keep the Change

Written by: Bob Spiel, MBA

Day One of OPIE Con is now wrapped up.   For all who are attending, what an amazing opportunity this is to learn from the very best in the Orthotics and Prosthetics profession.    Few things compare to the personal and group discoveries that occur when you step away from the demands of daily objectives, step into a world of learning, and then commit to new things.   For me personally, it’s been a thrill to be with you today, seeing light bulbs go off inside as breakthroughs take place.

Over the next two days, more courses will be taken, networking will occur, ideas will be fostered, hearts will be motivated, and then…Monday comes crashing back into our professional lives.   Within a week or two the lessons from the training get dimmer, the present realities loom larger, and the good intentions we had on the way back home become memories in a notebook.   We catch a bad case of “conference-itis”.

What can each participant at OPIE Con do to immunize themselves from this chronic condition so that the good intentions turn into goals, and the goals turn into results?  What can we do to “Keep the Change”?  To borrow a word from my key note session this morning, the answer is SIMPLE, UP-FRONT CLARITY.   In my experience as a practice coach, the action items from this conference have a 90% chance of success IF you invest the mental and emotional energy – sometime between now and Monday morning — to gain crystal clear answers to the following questions:

  1. What do you really want and why? Whether we like it or not, genuine change begins at an emotional, and not an intellectual level.   Emotions drive people, and people drive performance.   Tapping into this level begins with knowing exactly what you want, and, more importantly, why you want it.   This is the starting point of clarity, because after these two answers are in mind, the rest of the answers begin to fall into place.  Without these answers, change doesn’t stand a chance.  With them clearly in place, more than half the mental work is done.
  2. How important is this? Once the “why” is determined, the next question to consider is its level of importance.   What impact will this change have on your organization; on you personally; on your patients?   How big a deal is this…really?  These thoughts help sink the answers to question one further into our hearts, and also into our minds.
  3. What will success look like? With this change firmly in place, can you describe how things would run, look, feel, perform?   How will you know when success is reached and what the finish line looks like…if there is a finish line at all?
  4. How am I going to make this happen? Shifting to action planning is the fourth step.   For each point in this step keep in mind that you may not know the answer, but if you did, what would it look like?   Give yourself permission think out loud and start from where you are.  These three simple questions keep the clarity going:
    • What are the steps?
    • How do I/we go about making this happen? Who would be involved?
    • What is your goal completion date?  Remember, time is one of our greatest allies in getting things done.  If we don’t set realistic deadlines, tomorrow never comes.
  5. What’s the reward for getting there? For each major step in the process, what reward(s) could be put in place as mile posts for celebration?  If this is a team effort, could you employ a grab bag (a bag full of 5’s, 10’s, 20’s and a 50 dollar bill that each gets to grab into and see what they get)? What would also be a fitting, ultimate reward for achieving this change/goal?  A trip, cruise, night out, CE event, or time away?   The answers are only limited by our creativity.
  6. What’s the penalty for not nailing this? If the change isn’t sticking, is there an appropriate way to reinforce it by setting up negative reinforcers as well?  A client of mine has some very specific fitness goals, and each time he forgets to nail one of his commitments he puts $5.00 into a fishbowl in his office.  What’s the big deal about that?  He’s a loyal University of Georgia Bulldog, and the hair on his head stands up when he thinks of Auburn University.  The five dollar bills in the jar will be donated to Auburn’s booster club. The money isn’t the big deal; the thought of promoting Auburn is.
In summary, ideas don’t create change; ownership does.   These six steps are all about creating clear, genuine ownership both on the inside and outside, in order to create the future you want.   Conference-itis is not contagious.  We choose to catch it, or not.   Make this OPIE Con a game changer by cementing in place, before the vortex of the office sucks you in, clear answers to these six points.   You’ll find by doing so that you not only got your feet in front of you and kept them there, but will have created an unforgettable journey upward. And that bird Paul spoke of Thursday morning will be nurtured.

Make sure you sign up for the post-OPIE Con coaching sessions! They are another means of helping you ensure you don’t leave what you learned at the conference.  Sessions are free for all Choice members! Register Now!

Balancing the Art, Science, and Business of O&P

Written by: Scott Williamson, MBA, CAE(ret)

The delivery of O & P care has long been a blend of art and science.  The relative contribution of each can be debated, but certainly both are essential to provide effective care.  Today, with pressure on healthcare providers to do more with less, or at the very least, to continue to provide the same level of care that you are used to, you have to pay attention to the business side too.  We are being told that we need more documentation, more administrative support, and some insurance companies are offering rates at 40% off Medicare!You can not stay in the business for long without paying attention to the business side of your operations.  Managing your margin is essential to providing care to the people who need you.   At the same time, we can not allow the science and business of care delivery to overrun the art of care.  All three elements must be in balance for  high quality care and long-term success of your business.

Think of the Art of care as the “human” side.  You might be a great technical prosthetist or orthotist, always providing the perfect intervention and achieving the physical correction you are looking for. However, if you don’t make the human connection, if you don’t get to really know the person behind the challenge, then you  can’t fully address their needs.  It is not enough to treat the condition, we must treat the person.  When you first meet a potential patient, most likely at the initial evaluation, you should ask yourself three questions:

  1. How do I treat this person and not just the disease?
  2. What is it that they really want? (What will make this intervention a complete success for them?)
  3. How can I give the right people the right amount of authority as they participate in the care of this person?
Approach your plan of care from a perspective that balances the Art of care with the Science of care in such a way that the Business of care can continue.
Marketing Plans for O&P Offices

Target Marketing – Fail to Plan, Plan to Fail

Written by: Christy Butler, MBA

One of my favorite quotes is “If you fail to plan, you are planning to fail.” Doesn’t that ring true in so many aspects of our life, including our work?

Today though, I want to talk to you specifically about your marketing efforts.  Do you have a plan? Are your efforts targeted? Are you using the data already available in your system to drive your efforts?

The best way to create a solid marketing plan is to take your yearly organizational goals and break them down into quarterly strategic marketing goals.  After that, you should break those out into high-level monthly activities and detailed weekly and daily activities.  This will allow you to create a manageable plan with milestones for completing the plan and achieving your goals.  Additionally, by breaking your goals down into smaller chunks, your staff will have a clearer vision of what can be accomplished.

Your marketing plan can be as simple as an excel spreadsheet or a word document that you break down by quarter and month. As the Marketing Manager at OPIE, I do this.  I start out listing all of the months on a sheet, and then I add in all of the activities that I know will happen and when they will come into play.  In November or December I do an overall planning session for the year, and then I also work on Q1 goals.  In March, I complete Q2 planning, June is Q3 planning, and September is Q4 planning.

Try the Target Marketing Activity!

This is not a perfect process!  Other things will creep in as they always do, and things will need to be rearranged for various reasons.  I simply try to work out when I will need to do various activities for the year, and quarter by quarter and month by month I adjust and move things around in my plan as necessary.  Not only will this help to keep you on track to achieve your goals for the year, but it will also help you as you plan for future years.

So thus far, I haven’t even really discussed anything marketing specific, other than the word “marketing” a few times.  BUT, making a plan is more than half the battle! If you can do that, implementation of your marketing strategy becomes much easier.

So what do you need to ensure your marketing efforts are aligned with organizational efforts? I suggest working with your owner or business manager and asking them to provide you with at least yearly strategic initiatives (hint: these should align with your corporate mission statement). From there, sit down with your team and determine the following key things –

  • Your Purpose – Why does your organization exist?
  • Target Market – Who is your ideal customer?
  • Messaging – Why do your customers care about what you offer? What value do you create? Why are you different from every other O&P office out there?
  • Platform – Where do you tell your story? (What media will be used?)
  • MAKE IT ABOUT THEM (the customer), NOT YOU!!

Planning and answering these questions will put you at a huge advantage as you create or improve your marketing efforts. But remember: perception is reality…people choose to work with companies due to intangible value, for what they experience and what they care about. Your competitive advantage is what your customer believes, not the device you provide.

Join me at OPIE Con for a full session on taking a targeted approach to marketing. Register now!

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Spencer Penhart

OPIE Con, A Day in the Life…

Written By: Spencer Penhart, Penhart Performance GroupAs a former presenter at multiple OPIE Cons, I have had the unique perspective of experiencing several OPIE Con meetings and meeting hundreds and hundreds of the attendees. While every OPIE Con is a little bit different, here is what I have seen that is the same, and why you should attend…I see a group of over 200 people arrive at a terrific destination, city, and venue. They are from all over the U.S. and other countries, and some come with several clinicians and staff from their clinics.

They enter the ballroom for the opening session, often looking a bit nervous and uncomfortable. Many are first-timers, and they wear their inner monologue on their faces, all seemingly asking themselves the same questions: “Was this a good idea? Should I really be here? Is this going to be worth it?”

They then begin their opening session by meeting new people and making  friends. People are soon feeling much more comfortable. They then participate in a presentation that is both emotionally challenging and career-changing, redefining how they see their role in the clinic and how they can impact patients. It sets the stage for one of the most valuable benefits of OPIE Con: the mindset shift away from just doing transactional work, to doing your VERY BEST to positively impact patients and the practice. Then, a guest speaker usually presents on a key topic that is foundational for the success of any O&P employee and practice.

Day 1 is spent in breakout sessions with people from their same functional tracks: Clinician or Administrative/Billing. They improve their skills and knowledge, and another critical light bulb goes on for them: OPIE and Futura software systems aren’t just something their boss told them they have to use; these tools are critical  for providing the highest quality care for patients, as well as for ensuring maximum financial viability, efficiency, and success for the practice. They reconvene as a large group at the end of Day 1, seated with people from their same functional track but different practices, and share their key takeaways with one another. Yet another key OPIE Con takeaway: collaboration helps everyone be more successful. Day 1 ends with a really good party. I have personally witnessed Paul Prusakowski doing a fantastic salsa dance to the smooth Caribbean beats of a steel drum band and eaten delicious crab cakes at the oldest restaurant in Baltimore on a waterfront balcony while watching the Cleveland Browns ruin yet another NFL draft, just to name a couple! By this time, the attendees are having a great time, and making terrific new friends.

On Day 2, the focus begins to shift from working as a function to working cross-functionally throughout an entire clinic. It often begins with the Innovation Workshop, where attendees are seated at a table with clinicians, billing, and administrative personnel, all from different clinics. They then begin an open and honest exercise about where the biggest frustration points tend to be within each of the three functional areas. What they quickly see is, “It’s not just me or my practice that struggles with this, it’s everyone!”

They then move into an ideation session, where they work together to develop multiple specific solutions to the most common significant problems in each track and share those with the entire audience. Every single attendee witnesses 200(!) new ideas for how to solve that issue in their practice, and then hones in on the top 3 solutions they want to proactively bring back and discuss with the practice owner. One of my most interesting observations of this workshop is that it is often the first time the clinicians have ever heard of these issues existing, as they often are not shared with the clinician or practice owner out of fear of repercussions. The attendees then go on to complete their functional tracks in the afternoon and are brought together at the end of the day for a final idea sharing session, this time seated with all the people they came with from their practice. They share their key opportunities for improvement both as individuals and as a practice and begin the process of action planning to resolve them. This is among the biggest gold nugget you could imagine from a conference. On Day 3, they attend a few final sessions, then head home with a new perspective, brimming with both possibility and newfound responsibility.

I saw the same result every time. OPIE Con is truly an impactful and memorable experience that can transform your practice. To get the maximum ROI, I would recommend not just sending one person from your office, but all key personnel at all the levels: the Clinician, Office Manager, Biller, Administrator, etc. It’s the opportunity to take your practice’s success to the level you hardly dared to imagine…

Register for OPIE Con Now

Financial Success in an O&P Practice

Planting the Seeds for Financial Success

Written By: Darren Donnelly, CO, MBA

The Top 4 Things You Can do to Feel Financially Secure

Financial Security is the peace of mind you feel when you aren’t worried about your income being enough to cover your expenses. It also means that you have enough money saved to cover emergencies and your future financial goals. Knowing how much money you need to feel financially secure in your business is not easy and it is not the same for everyone.  The top four things you can do to increase your feeling of financial security are: 

  1. Eliminate debt,
  2. Control your expenses,
  3. Increase your sales and assets,
  4. Have an exit plan

Financial Security in O&P

Financial security can come from having a significant amount of profit. Profit is defined as the surplus of money remaining once costs have been removed from total revenue. A simple way of saying that is that profit equals sales minus costs. Sales in O&P are realized as reimbursements from third party payers or direct payments from our patients. Costs are the cash and other resources we spend. Orthotics and Prosthetics is an example of what I like to call, “product-based health care.” There will always be high costs because we either buy finished products or purchase the parts to fabricate a tangible product to deliver to our patients.

Profit is a mathematical equation. This means we have the ability to alter the numbers to affect the outcome. To increase profit, we must either increase sales or decrease costs. It sounds really simple, and it can be, but you have to learn which side of the equation you can control.

Is Increasing Sales The Easiest Road to Higher Profitability?
Even though “sales” is just one side of the equation, there are several ways to change the number. To increase sales we could get more work by expanding our referral base, adding a new product line, or a number of other things that would increase sales volume. But when we increase our sales we are most likely also increasing our costs. To provide more products we have to buy more materials. The ratio of costs to sales probably stays the same. Increasing sales without increasing cost is really tricky. Also in product-based health care, just because you provided a device does not necessarily mean you will get paid for it. Your sales are only as good as your receivables. If there is anything to focus on when it comes to your sales, it is your receivables. Monitoring your aging accounts receivables and collecting your money will increase your profit and in turn your financial security.What About Focusing on Decreasing Costs?
The other side of the equation is a little more controllable. We can, in fact, decrease our costs without decreasing our sales. By implementing a few materials management strategies we can control our spending. To maximize your bottom line, the top four things you should focus on to reduce costs are:

1. Monitoring your purchasing habits
2. Establishing discounts with suppliers
3. Managing inbound shipping costs
4. Utilizing inventory

If you implement those items into your workflow(s), you will begin the process of managing your cost of materials. Material cost can add up to over 33% of your total office expenses. Payroll is another third and rent, utilities and everything else is the last third of your cost. It is very difficult to change your payroll expenses without effecting productivity. While renegotiating rent or utilities may be possible it is certainly harder than managing your cost of materials.

The areas in your organization with which you have the greatest ability to control your costs and profitability are materials management and collections. If you focus on those two areas, you will be closer to peace of mind and financial security.

Do you want a full, in-person session on materials management and decreasing costs? Join us for the Office Management track at OPIE Con to get that and so much more! Register now!

Register for OPIE Con Now

Medical Necessity: It Takes A Village

Written By: Chris Doerger, CP, PTProviding O&P care can be a very rewarding profession on many levels, not the least of which is the personal sense of accomplishment you get when your patients succeed.  Regardless of your motivation to enter into the profession, you stay in it because you care. The orthotics and prosthetics profession is made up of some of the most passionate, caring and fun individuals you will ever meet, and a common driver is to do whatever they can to help their patients! Those are commendable qualities, but they can present a dilemma when it comes to making money as an O&P provider.

As the tide continues to shift in healthcare, you might begin to realize that insurance companies don’t think like you do.  You are feeling pressure as they look more closely at the care you are providing and whether or not it aligns with the patient’s functional abilities and their forecasted outcomes. And, that’s why it takes your entire team to ensure you provide the highest level of care to your patients while creating the documentation that will get you paid.

These days, very few tasks in any O&P facility are accomplished by a single individual.  Healthcare in the current climate is a team effort: understanding and appropriately documenting medical necessity is no exception.

What is Medical Necessity?

Medical necessity is a term that, while frequently used in our profession, is often misunderstood.  Medical necessity is a legal doctrine.  Though this definition seems simple enough, the principles which underpin the concept can be complex.  Medical necessity is found where insurance coverage decisions intersect with medical decisions.   Of course, the hope is that coverage decisions and medical decisions remain independent, but as most of us know, it is not always that simple.

An individual’s insurance coverage is a contract between the plan manager and the beneficiary.  Medical decisions are the result of the clinical decisions made by the provider after evaluating and discussing treatment options with the patient.  Medical necessity enters the conversation once a decision is made for a medical care to be covered by insurance. At this point, any dispute will be resolved by ensuring that the care provided was reasonable and necessary.  This is the essence of medical necessity.  Medical necessity should not be influenced by the insurance coverage.

 The complexity of medical necessity is not only owed to its definition.  Medicare defines medical necessity as, “services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”  If we were left to that definition alone, perhaps solving the riddle of medical necessity would be easier.  However, there are additional considerations. 

  • One is determining the appropriate frequency of the provision of care.
  • Another is that we don’t deal solely with Medicare.  Private insurers may attach exclusions or riders to this definition.  This means that we must understand medical necessity in general terms, abide by the regional local coverage determination, and also ensure we are fully informed regarding a private payor’s medical policies. That is a great deal of information to process.

So, What Can You Do To Ensure You Prove Medical Necessity?

The clinician plays a large role in determining medical necessity during each episode of care. While the administrative and billing team solve the puzzle on the payor side, the practitioner must provide a thorough evaluation of the patient.

  1. It is critical to establish that the care provided is consistent with the severity of the patient’s diagnosis and current functional status. The best way to do this is to establish the patient’s prior level of function, and then clearly define what has changed in the patient’s condition since the injury or illness.  That disparity is the clinician’s reason to intervene. 
  2. The clinician must also document that services provided are safe and effective according to best practice.
  3. Lastly, there should be a reasonable expectation that the patient’s functional ability will improve. If we objectively document the patient’s impairments and apply appropriate outcome measures, then demonstrating positive improvements is a relatively simple task. 

Are you ready to take your clinical documentation to the next level?  Do you want to learn the goals and outcomes approach to clinical notes that will help you reduce your denials? 

Join us at OPIE Con, May 3-5, 2018, Tampa FL. Register Now! 


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I’ve Seen Your Future … and it Looks Amazing!

I’ve Seen Your Future … and it Looks Amazing!
(with the right things in place)

Bob Spiel, MBA

The future for orthotics and prosthetics is brighter than it’s ever been.   I don’t say this because of new materials, technology, or applications, or even because of  cutting edge tools like OPIE.   I make this claim because a paradigm shift is taking place bit by bit in practices throughout the country. This shift is transforming O&P practices from “job shops” to “focused factories.” In simpler terms, it means there is a mindset change from me to we – and this change revolutionizes everything.  It becomes the springboard for amazing levels of patient service, team fulfillment, group rewards and clinical outcomes.


How can I make such a bold claim?  Because I’ve seen your future.  For the past 10+ years I’ve had the opportunity to spend a large part of my time consulting in dentistry – a profession that has been spotlighted by thought leaders as a model for the future O&P practice.   Dentistry went through the very same paradigm shift over 30 years ago that O&P is experiencing now.  Walk into a dental office and it is rare to find a doctor doing it “all.”   Dentists have learned their practice is efficient, effective, and financially stronger when the dentist only does what they have to do — and delegates the rest to well-trained team members.


Now, are O&P and dentistry really that similar?  While they work on different parts of the body, the differences end there.  Both dentistry and O&P are time focused settings where the patient is awake, the services are intimate and personal in nature, pain is an outcome if not done with the highest level of quality, and a practitioner/provider needs to be there for parts of the patient visit, but not all of it.   Dentistry and O&P also rely heavily on referrals, while also gaining patients directly from marketing efforts and word of mouth – so excellent customer care is of supreme importance.


Given these parallels, then, what are some of the lessons any O&P practice can pick up from dentistry to propel  into this bright future?   What are some of the right things that must be in place to reach new levels of effectiveness, efficiency, and profits?


First – extreme focus.  Like all effective teams, great dental teams maintain a heightened level of personal and group focus.  They have a very intentional scheduling template for each provider, a plan for the day, they discuss that plan before the day begins, and work to execute that plan.  They are also aware of their group and individual goals, group metrics, and how they are doing against those.   These teams use the goals and metrics as motivators to provide even greater levels of service and performance.


Second – a commitment to each team member doing their highest and best.  In the book, Good to Great, Jim Collins describes the importance of getting the right people in the right seats on “the bus.” Finding the right seats for your team members boils down to answering the question: “What responsibility can be given to use both their very best capabilities, and then allow those capabilities to complement the skills and strengths of everybody else?”   This exercise is clarifying, empowering, and may lead to realizing some team members may need a different bus.


Third – no “silos.”   The division between “front” and “back” doesn’t exist in truly great teams because such separation negatively impacts patient care, practice morale, and overall practice performance.   Turf is only good on a ball field – not in an office.


Lastly – dedication to always learning and improving.  While a dentist might feel out of place at OPIE Con, it certainly is THE place for your practice to learn about the tools AND mindsets needed to begin to take your O&P practice to this next level of performance.   As Stephen Covey taught so many years ago, there can be a shift in interpersonal involvement from in-dependence to inter-dependence.  It is at the point of interdependence that 1 plus 1 equals 3, 4, 5 or even more.


OPIE Con 2018 will help pave the way for you and your team to make this happen with the tools and training to embrace this future.  It will be my privilege to be a part of “paving the way” in May.  I look forward to meeting you there!


Register for OPIE Con Now



Getting And Keeping Your Money

Getting and Keeping Your Money:
Managing Audits, Denials, and Appeals

   Lesleigh Sisson, OPIE Consultant

If you manage an orthotic and prosthetic practice, you know that the fiscal health of your business relies on effective and compliant billing. While that seems straightforward enough, the scrutiny of the Office of the Inspector General (OIG) has underlined the importance of doing things the right way, the first time, so you can get and keep your money and avoid costly audits and denials.

The simple truth is that 90 percent of denials are preventable, and 2 out of 3 denials are recoverable. I’m going to share some strategies for getting and keeping your money by successfully managing audits, denials, and appeals.

What Can We Do?


That’s obvious enough, but incredibly true. According to Haines and Morgan, 90 percent of denials are avoidable. That means that we have the power to make sure they don’t happen to us, or to our patients.

Why Do Denials Happen?

Understanding why denials happen can help us to prevent them. Most denials occur because of the following:

  • Ineligible/Uncovered Services
  • Failure to Obtain Prior Authorization
  • Lack of Proven Medical Necessity
    • Medical Records
      • Diagnosis
  • Incomplete or Inaccurate Patient Demographic Information
  • Service Covered by Another Plan/Payer
How Can We Prevent Denials?

Now that we know the basis for most denials, we can see that prevention is in the hands of your entire office. Right now we will focus on how the front office can work effectively to prevent denials. Investing in your billing practices will save time- and money- in the long run. These should be a mainstay in your front office procedures:


  • Thorough Patient Intake and Accurate Data Entry
  • Insurance Verification and Prior Authorization
  • Obtaining External Medical Records for Patients
  • Ensuring Clinical Documentation is Complete and Compliant
  • Scrubbing the Bill/Claim Prior to Submittal


What Should We Do if We Are Audited?

Audits happen. The most important thing for you to do is not to panic and to make sure you follow these steps:

  • Respond in a Timely Manner
  • Do NOT Fail to Respond (even if the amount is low, you do not want an error on record)
  • Be Polite
  • Keep Track of ALL Correspondence
  • Thoroughly Respond to the Request
  • Do NOT Alter Records in ANY Way
  • Request “Return Receipt” When You Send Records
  • Ask when You Will Receive a Response
What About Appeals?

If your claim is denied outright or after an audit process, and you disagree with the findings, you can issue an appeal. Remember, 2 out of 3 denials are recoverable. That’s because the denial is usually based on incorrect or incomplete information. The appeal is your opportunity to make things right. Not only is it generally in the patient’s best interest, it will also help you tighten your own processes and, quite possibly, receive the funds you’re hoping for.

What’s the Bottom Line?

While it’s true that O & P practices are subject to denials and audits now more than ever, it’s also true that we have the power to get and keep our money through solid front office/billing procedures and proper management of audits and appeals.

Want more tips and tricks on how to get and keep your money?  Join us at OPIE Con for full sessions with Lesleigh! Register now


L Code Justifications

L Code Justifications
Chris Doerger, CP, PT





Raise your hand if you got into O&P care because of how much you love writing justifications. If this is you, you are a rare breed indeed! Unfortunately, thorough justifications are an important part of O&P clinical practice…they provide a clear perspective of the clinical thought process that went into your decision making. Comprehensive justifications allow our allied healthcare peers and referring physicians insight into our plan of care, and are the beginning of all insurance submissions. Much like modifying a plaster cast writing justifications is both science and art.  It takes practice to get it right.


As practitioners, our job is to improve each patient’s quality of life.  It takes a team of professionals working together to achieve our goals.  Clear documentation is the best way to effectively communicate with our rehab team and payers.   We gather data in the form of subjective history and objective tests and measures.  We then use our clinical judgment, clinical education, and available medical evidence to assess the patient’s condition.  If this assessment is distilled down to the basics, we are documenting why we have chosen a specific treatment plan for this specific patient.   Medical necessity is a legal doctrine that describes any activities which may be justified as reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care.   This legal doctrine provides the context for our justifications.


Here are a few key steps to writing a good justification:



Step 1:

Give a brief, lay description of the code. This description should be clear even to nonclinical personnel.





Step 2:

Explain how this code contributes to the function of the overall prosthesis or orthosis.  What benefits does this base code or feature provide?  These can be general benefits.  For instance, L5845 describes the stance flexion feature of a prosthetic knee.  A general benefit could be described as, “During normal human locomotion, stance flexion of the knee absorbs the initial impact of the heel with the ground, maintains forward momentum of the body, and                                                                            limits large excursions of the center of mass.” Of course, this is a brief example.  If needed, a longer or more                                                                                       detailed explanation may be written.




Step 3:

Once we’ve described the code in lay terms and explained the benefits, we must relate how this code will improve our patient’s function.  This should be a more specific explanation.  What activities does this patient need to complete, and how will this code help them accomplish those tasks?  The activities we should emphasize are mobility and mobility-related ADLs.  This would include gait, transfers, toileting, dressing, bathing, feeding, and other self-care activities.  It can also include
functional vocational tasks.




 Step 4:

Finally, one of the last elements of justification that you might include are references that support your code     narrative.


Code justifications are only part of the medical necessity puzzle.  You may find that additional explanations for your choice of orthosis or prosthesis are appropriate.  One example is the use of a microprocessor knee for a transfemoral patient, instead of a less-expensive hydraulic knee.  You may need to document in your assessment that a mechanical knee trial was performed and found to be inadequate to meet the patient’s needs.   You may also need to document that, though initially more expensive, a microprocessor knee has a greater ability to prevent future injury and related medical costs.  As with other code justifications, this should be supported by appropriate references.


OPIE Con 2018 will provide a forum to advance your knowledge on this subject.  The Clinical Management track will be covering the essentials of medical necessity in a collaborative fashion.  This will include lectures, discussions, and (most importantly) hands-on practice to improve our ability to document effectively.  Please join us!