Medicare Proposes Narrow Definition of Off-the-Shelf for Competitive Bidding

The Centers for Medicare and Medicaid Services (CMS) crafted a narrow definition of the off-the-shelf orthoses that could be subject to a competitive bidding program, according to an American Orthotic & Prosthetic Association (AOPA) press release.

Under this new definition, off-the-shelf devices will be limited to those that “require minimal self-adjustment for appropriate use and do not require expertise in trimming, bending, molding, assembling or customizing to fit the individual.”

CMS also proposes that “minimal self-adjustment” mean adjustments that a beneficiary, caregiver or supplier can perform without the assistance of a certified orthotist. A certified orthotist is defined by CMS as someone certified by either the American Board for Certification in Orthotics and Prosthetics Inc., or the Board for Orthotist/Prosthetist Certification.

This proposal, which grew out of the Medicare Modernization Act of 2003, is included in the notice of proposed rulemaking for the competitive acquisition for certain durable medical equipment, prosthetics, orthotics and supplies published by the Department of Health and Human Services on April 24.

AOPA president Walter R. Racette, CPO, said, “the approach recommended by CMS is a giant leap toward improving the quality of care available to Medicare beneficiaries who require orthotic and prosthetic services and will reduce opportunities for fraud and abuse by unscrupulous Medicare providers. It also further differentiates O&P from durable medical equipment and recognizes that the provision of comprehensive O&P care requires a level of clinical knowledge and expertise unique to a certified practitioner. AOPA has been a long-time proponent of each of these positions.”

“It is clear that this proposal will be strongly challenged by other interests, yet AOPA and its partners in the Orthotic and Prosthetic Alliance will work diligently to see that the proposal remains intact in the final regulation that will be issued by Medicare later this year,” added AOPA executive director Tyler Wilson.

Had such an approach been in place sooner, it is possible that some of the most egregious examples of fraud relating to O&P, including the 2004 Florida case in which 21,000 prostheses were paid for by Medicare at a cost of more than $120 million of taxpayer money, could have been prevented.

With the publication of the notice of proposed rulemaking, AOPA sees the longtime efforts of the association and the other members of the Orthotic and Prosthetic Alliance coming to fruition. AOPA hopes that O&P professionals will recognize the significance of this development and play an active role in continuing the political momentum that has been established.

A summary of the Medicare competitive bidding proposal was distributed to AOPA members in May.

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