Industry Leaders Anticipate Tough Legislative Battles information_schema 2011

When it comes to the big picture, the O&P industry is a small player
in swaying key legislative decisions. The industry accounts for less than 1% of
Medicare expenditures. While it is not expected that the major O&P
organizations agree 100% of the time, in the past few years they have fostered
an understanding that it is crucial to remain coordinated and organized when
promoting key legislative principals. The industry simply can not afford to
have different points of view from such a small field.

Affordable Care Act

Affordable Care Act passed by Congress and signed into law in
March 2010 is clearly the piece of legislation that will continue to have the
biggest affect on the industry moving forward.

© 2010 iStockphoto Dwight
Nadig/Getty Images, Inc./Image Source

“Our key interest in this past legislative cycle has been health
care reform,” Kendra Calhoun, president and chief executive officer of the
Amputee Coalition of America (ACA) explained to O&P Business
. “With the new Republican-controlled house, there is talk of
repeal or defunding portions of the health care reform bill. I can not really
predict what the bill is going to look like going forward.”

According to Tom Fise, executive director of the American Orthotic and
Prosthetic Association (AOPA), the industry did reasonably well in avoiding
major cuts as a result of the bill.

  Kendra Calhoun
  Kendra Calhoun

“The one negative thing that occurred for us is something that
occurred for relatively every subdivision of providers, which was the
productivity adjustment reducing the fee schedule amount,” Fise explained.
“Estimates are at approximately 1% per year.”

The fee schedule that was published reflects this decrease. There is
virtually a flat fee schedule for O&P going into 2011, Fise said.

“That is a negative, but one that was spread across the roughly
$500 billion’s worth of Medicare cuts that was part of the bill,” he

The medical device tax, embedded in the Affordable Care Act, imposes a
2.3% excise tax on the sale and import of Class I, II and III medical devices
beginning in 2013. According to Fise, the tax is still on the road to
implementation. Fise suspected that there will be efforts to repeal or modify

“It came about in an unusual way,” Fise explained. “In
the final hours, as the bill was being voted on in the House, the provision was
changed and that is how we ended up with a tax for nearly all devices. There
are some potential exemptions as it pertains to O&P that we will be

Injured and Amputee Veterans Bill of Rights

The Injured and Amputee Veterans Bill of Rights, (HR 5428) is
a bill that has yet to be passed by the 111th Congress as of press time.
Currently, the House has passed the bill, but it has yet to be passed by the

“It is an important bill and I think it will be hard for anyone to
be opposed to it,” Fise said.

The bill ensures that veterans are aware of their rights to care,
including the right to have their care provided by a medical center other than
the Veterans Affairs centers. In the House, the bill was combined with the
Women Veterans Bill of Rights. There were some concerns expressed about that
bill, but ultimately all concerns were laid to rest and approved by the House.

According to Fise, there is talk of separating the two bills so the
Injured and Amputee Bill of Rights could be voted on its own merits, but that
has yet to happen.

  Tom Fise
  Tom Fise

“My confidence level is high because we have good people working on
that bill and it is a good cause,” Calhoun said. “I don’t have a
crystal ball, but I can say the ACA will support it.”

If the bill does not pass in the 111th Congress, then there will be an
effort to pass it in the 112th. If this bill is not passed by the Senate before
they adjourn, then the whole process must start over again.

“It would be as if the House vote to approve this bill did not
happen — you have to get both Houses in the same Congress to approve the
bill,” Fise said. “It would be a lot easier at this point, because
one House has voted already. If that does not happen, there will be an effort
to start over again in the new Congress.”

New relationships

Calhoun admitted that 2011 could potentially be a challenging
legislative year due to the large turnover in the House.

“It is going to be challenging in Congress because of the new
Congress — not because Republicans own the majority — but because it
is a different challenge than a democratically controlled Congress. There was
so much turnover and so many new people,” she said. “Politics is like
health care — it is all about relationships. You spend a lot of time on
these relationships and then you have to start all over.”

Despite being unfamiliar with the players involved, the industry’s
core principals and messages still need to be heard.

CMS Improves Communications Regarding Internet-Based PECOS

The Internet-based provider enrollment chain and ownership
system (PECOS) implementation date has been modified numerous times —
causing confusion among practitioners. The O&P industry has been
particularly frustrated with the lack of communication between CMS and the
referring physicians who have failed to enroll in Internet-based
PECOS. Informational messages are still being sent out and are
worrying practitioners whose referring physicians have yet to enroll in the

implementation date continued.

“There were some communication concerns in the industry
saying that it would be implemented on Jan. 3, 2011,” Laureno said.
“We have not yet given a date when the ordering and referring edits will
be turned on.”

In order to curb further confusion and correct any failings,
CMS created a team and brought people from across their organization including
information systems, policy employees and CPI representatives, to make
improvements to the current system. The improvements are expected to be made in
January and April of this year.

“In terms of the database system, we will be making it
more intuitive, user-friendly and stable,” Laureno explained. “There
were complaints about the system going down or being too slow. We spent a great
deal of time on system performance.”

On Oct. 29, 2010, CMS brought in representatives of
providers and organizations that were enrolling large volumes of physicians
such as hospitals or large independent physician practices and spent a full day
talking to them about what types of developments would help improve PECOS.

“We have had a lot of direct communications with the
provider and physicians. Out of the meeting with the providers, they said
‘if you could do anything, get the word out there regarding the ordering
and referring date,’” Laureno said.

As of press time, CMS had not released an implementation

  Mary Agnes Laureno

“We have to fight a bigger uphill battle and we have to make our
voices a little louder, but we have to make them united,” Anita
Liberman-Lampear, MA, member of the AOPA government relations committee, said.

One voice

There are many individuals called upon throughout the year to contact
their representatives and many contributors to acknowledge, according to Fise.
These individuals, along with industry leaders have helped to spread the
message of the O&P profession.

“AOPA has geared up significantly on the legislative side in the
past 3 years,” Fise explained. “We have engaged two outside lobbying
firms, every Friday the AOPA lobbyists have a call and Peter Thomas is invited
to be in on that call. He would represent the O&P Alliance. They talk,
coordinate and organize and simply help each other out.”

Each week, AOPA has a call with ACA. The idea behind this constant
communication is to make sure every resource that moves legislative and
regulatory issues along is being used and that no one is caught by surprise.

  Anita Liberman-Lampear
  Anita Liberman-

“It is a matter of having to stay on top of it,”
Liberman-Lampear said. “We need to continually get that message out.”

Liberman-Lampear has gone to Capitol Hill four times throughout the
years to get the industry’s message out. She would discuss parity and
other issues that concern the O&P field with key legislators and their

“We have to talk to representatives with one voice,”
Liberman-Lampear explained. “You can’t have different people coming
in from the same industry asking for different things. Too many people from too
many industries are asking representatives for help.”

Medicare O&P Improvements Act

O&P organizations and industry leaders need to maintain their clear
message because two bills that did not pass in 2010 have the potential to be
enacted in 2011, according to Fise. They are the
Medicare O&P Improvements Act and the Federal O&P
Parity Bill.

Through the O&P Improvements Act (HR 2479) Medicare would not
continue to pay providers who are violating state law by practicing without a
license for states where there is a licensure statute.

For the first time, the bill would also link payment to the
qualifications of providers. There would be a different set of requirements for
each level of complexity in O&P that providers would have to meet in order
to be paid by Medicare, according to Fise.

“The bill has potential because it would cut down on fraud and
abuse by unlicensed or unqualified providers,” Fise explained. “It
would actually save the government some money. Because of this, it will have
some strong prospects going forward and could potentially be enacted in the
next Congress. I think the time will be right for this because there is so much
pressure to save money.”

The Federal O&P Parity Bill

The Federal O&P
Parity Bill was introduced in both houses this year (HR2575
and S3223). Unfortunately it was not passed in this legislative session.
Without a federal law on file, the state laws will only cover certain plans
within each state. It is vital for not only those states where parity has not
yet been passed, but also for those with laws on the books to get a federal
campaign passed to ensure coverage for everyone.

There have been parity laws established in 19 states. If an insurance
plan is a state which has enacted parity offers an O&P benefit, then it
must be on the same basis of the general medical and surgical care that is
offered in their plan. There are a fair number of openings for those concepts
to be enacted under regulations in the new health care reform law, according to

“We will be lobbying for the adoption of as much of that
legislation via regulations as we can,” Fise said.

For Liberman-Lampear’s state, Michigan, passing a state parity bill
has been extremely difficult.

“It has been tough,” Liberman-Lampear explained. “It was
introduced and then mostly ignored. I am fully behind the ACA and AOPA’s
efforts. I think it is really important. What I still have not been able to
sort out in my own mind is what it will look like in the Affordable Care Act. I
am not sure what this is all going to mean. I think most of us are still not
sure what it will look like for the O&P industry.”

Calhoun agreed that the due to the limited amount of knowledge on the
Affordable Care Act, the O&P parity legislative momentum was severely
halted this year.

“We had some stalling out in parity in 2010 but we will be back at
it for 2011,” Calhoun explained. “We anticipate at least 14 states
introducing a parity bill in 2011 and we have been organizing meetings across
the country. When you start over, you usually have some relationships in place
to jump-start the process, but that will not be the case with so much turnover.
Reintroducing the parity bill requires relationship building as well.”

Looking ahead in 2011

Looking ahead in 2011, state laws, particularly related to Medicaid are
becoming more and more important. States are pressed financially and are trying
to cut back on their Medicare and Medicaid expenditures by dropping benefits.
According to Fise, that is something the O&P industry will be forced to
keep an eye on.

The ACA, in order to be heard, turned to the media to discuss a timely

“We were concerned about the way amputees were being treated while
going through security at the airports,” Calhoun said.

The ACA wanted to develop a more effective and respectful process when
dealing with amputees during Transportation Security Administration (TSA)

“I received an e-mail about how one amputee was treated and then
another and they came on the heels of one another,” Calhoun explained.
“It was kind of my tipping point.”

Instead of waiting for the language to be implemented and enacted, the
ACA surveyed their constituents. Armed with data, they went to the media.

“We received press coverage around the country and the TSA called
us and we have been working with them to improve their processes ever
since,” she said. “It is slow moving, but I do think their intention
is positive and we will see how the implementation is in the coming

There will also be a resolution in 2011 to name the month of April Limb
Loss Awareness Month.

“We start from the big mega issues like the Affordable Care Act and
those things have an effect on everyone, but some of the things that are still
in the works like Medicare and parity bills are specific to O&P,” Fise
explained. “They are a little harder to get people’s attention and a
little harder to get them passed, but important nonetheless.” — by
Anthony Calabro

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