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Getting Paid Below Medicare

This week several of us went to Capitol Hill to speak for the O&P Clinical Profession. If you were there, thank you.  If not, you can still make a valuable contribution.  We spoke with our elected representatives to encourage them to support a bill that has high-powered bipartisan support.  While it may feel futile to try to get the US Congress to do anything meaningful, this bill seems to have a good chance of going through.  But it NEEDS YOUR support.  Membership in AOPA is not necessary to support this.  They are coordinating the effort, but they are not working in a vacuum.  All of the O&P national organizations support this effort as well as the national organizations of other healthcare professionals. In an O&P legislation rarity, there are no serious objections to the requests we are making.

For over two decades, people in this profession have complained about how unfairly Medicare treats them. And for the life of me, I do not understand how the private payers get away with “below Medicare” reimbursement for O&P services.  Maybe our profession is so disrespected because unless you have inside knowledge, people fundamentally do not understand that O&P is not DME…At least not from a real-life standpoint.  Unfortunately, when the Social Security Act was written, the omission of a couple of key words has cursed us into equal coexistence with sellers of diabetic test strips. This proposed legislation will make it crystal clear that the provision of orthotic or prosthetic Clinical Care is not the same as the provision of traditional DME.

Senators Mark Warner (D-VA), Steve Daines (R-MT), Tammy Duckworth (D-IL), Chuck Grassley (R-IA), John Cornyn (R-TX), Bill Cassidy (R-LA), John Thune (R-SD) C0-Authored the Senate bill, which has identical wording to the house bill.  Today, we are on the hill to encourage more cosponsors of these two bills, known as the “Medicare Orthotic and Prosthetic Patient-Centered Care Act.”

Picture of the US Capitol

Referencing the document linked above and provided by AOPA, there are four key goals of this legislation:

  • Differentiate O&P Clinical Care from Durable Medical Equipment: The legislation would statutorily differentiate the clinical, service-oriented nature in which O&P care is provided from durable medical equipment (DME). DME is totally different than O&P care and should be treated separately in statute and regulations. O&P clinical care would no longer be viewed through a DME lens, permitting more appropriate regulation.

 

  • Refine Competitive Bidding of Off-the-Shelf Orthotics: the legislation revises the interpretation of “off-the-shelf” (OTS) orthotics for purposes of competitive bidding by clarifying that the Centers for Medicare and Medicaid Services may only competitively bid orthoses that require “minimal self-adjustment” by patients themselves, restoring congressional intent and ensuring that patients in need of custom fit orthoses will continue to have the clinical care necessary to achieve proper orthotic fit and function.

 

  • Exempt appropriately credentialed clinicians from Competitive Bidding: This bill would exempt certified and/or licensed orthotists and prosthetists from the requirement to have a competitive bidding contract to provide OTS orthoses to their patients, much like the law treats therapists and physicians. These orthoses would be subject to the competitive bidding rate so this provision would increase patient convenience without increasing Medicare outlays.

 

  • Prohibit “Drop Shipping” of Custom Fit and Fabricated O&P: The bill would reduce waste, fraud, and abuse by prohibiting “drop shipping” of all prosthetic limbs and orthotic braces that are not truly OTS (i.e., subject to minimal self–adjustment by the patient). This would save Medicare outlays and ensure the provision of clinical O&P care.

 

While these four goals may seem small, they are the crucial groundwork for further legislative action. Getting these measures codified will ensure orthotic and prosthetic (“O&P”) patients have access to quality care and will reduce fraud and abuse in the Medicare O&P benefit. Specifically, this legislation will fundamentally ensure that patients are receiving the best quality care by licensed, credentialed, and trained professionals, guarantee that patient care is easily accessible, and reduce fraud and abuse that carries both a patient care and financial cost.

To move this legislation forward, we need to garner as much support as possible for it. Please write to your Representative and urge them to support this important legislation – simply enter your information on the platform, personalize the letter as you see fit – it’s important to tell YOUR story – and click send. The process will take you just a few minutes; however, educating Congress on the issues surrounding the O&P profession is vital to businesses and more importantly patients – if we don’t advocate for our needs and the needs of patients, no one will.

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