Issues with audits performed by CMS are increasing in prevalence and severity. Payment denials, claims of fraud and overpayment and lengthy appeals processes are causing significant delays for device deliveries and reimbursement, increasing administrative costs and distracting practitioners from providing optimum patient care.

“The process that CMS has in place has had devastating effects on businesses and patient care,” Dennis Clark, CPO, president of the Orthotic and Prosthetic Group of America (OPGA), told O&P Business News. “A lot of the patients that we work with in the O&P profession are inherently at-risk patients, and by delaying that patient care, it puts those patients at more risk.”


Dennis Clark


There are several types of CMS audits, but those affecting the most practices are conducted by recovery audit contractors (RACs) who receive a commission based on the amount of money they recover.

“There is no incentive for these independent contractors to double check things,” Ryan Ball, the director of government relations for OPGA, said. “And there is little oversight for this audit process.”

The headaches caused by these audits are especially detrimental to independent O&P clinics, because they often do not have the staff or resources to effectively deal with rejected CMS claims or endure the appeal process, which can last anywhere from 12 months to 18 months.


Ryan Ball


“They often do not have the resources or the personnel to be able to effectively defend themselves or the knowledge base to know where to turn for assistance,” Todd Eagen, vice president of OPGA, said. If a practitioner has the resources and knowledge to appeal a claim, three-quarters of appeals are thrown out by an administrative law judge.

“If something is getting overturned three-quarters of the time, there is something systemically wrong,” Ball said. “We want to empower independent O&P practitioners to speak out about this. It is a tough issue for them because it involves fraud, or supposed fraud, but at the end of the day, a lot of what CMS is calling fraud is not fraud.”

“Our charge is to provide services and resources to help these small business owners survive and thrive in trying times,” Eagen added.

After receiving countless complaints about CMS audits from members of the O&P community, OPGA took the issue to their local congressmen in Iowa.

“Their directive toward us was that this issue makes no sense,” Ball said. “And in order to be able to get CMS to do something about it, we are going to need a groundswell of people coming forward and explaining how it is affecting them negatively, and that includes the patients we all serve.”


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Based on these meetings, OPGA developed, a website forum where independent practitioners can relate their experiences with CMS audits.

“What we are trying to do is create a platform and landing site for practitioners and business owners to tell their stories,” Clark said. “And if they are willing to share their stories about how this new regulatory action is affecting them, we will be certain here at OPGA that the information gets to the appropriate congressional representation.”


Practitioners can submit their stories with the form provided on the website, as well as create a video relating their experiences that will also be posted online. The forum is available to any independent practitioner, and once a practitioner has submitted his or her story, a representative from OPGA will contact the practitioner to discuss the next steps that should be taken.

“We will personally follow up with them to talk more about their story and walk them through how to post a video to the website and craft letters to their members of Congress,” Ball said. “We will make sure they are able to send them to the proper staff and coach them on how to follow up and make sure that the letter is seen and acted on.”

OPGA also plans to make the forum available to patients, so they can recount how CMS audits have been affecting their care and experience.

“That is where the real numbers are,” Clark said. “There are 2,300 independent O&P shops, and if each one of them has 1,000 patients, then we can get real numbers of constituents that elected officials will care about.”

A need for change

Eventually, OPGA expects to create a larger report broken down by state that will be taken directly to CMS with the goal of reforming the most problematic aspects of the system.

“Our main goal is to create a groundswell of activity directed at members of Congress and have them contact CMS to talk about this,” Ball said. “We want to work with CMS on prevention efforts.”

According to Ball, he believes that enforcing qualification criteria and only reimbursing licensed or certified practitioners will reduce fraud. He also thinks that while the physician is a valuable part of the process of recommending and fitting O&P devices, the opinion of the orthotists and prosthetists should be taken as justification for functional status and componentry, rather than being required to have necessary documentation in the physicians’ notes. Increasing a practitioner’s authority could significantly decrease the amount of claims that are being audited for documentation issues.

“[This system] basically tells practitioners that their word and expertise means nothing,” Ball said. “Their notes could be perfect, but it doesn’t matter. If it isn’t in the physician’s notes, the claim gets denied.”

However, if an O&P practitioner did not have to rely on a physician to complete a claim, it could save a lot of time and aggravation.

“It could reduce the number of audits and the number of headaches these folks are going through,” Ball said. “And they will be able to go back to focusing on what they should be focusing on, which is how best to treat their patients and how best to provide them with additional functionality.”

Ultimately, depends on the practitioners, who must be willing to share their own stories and experiences in order for this initiative to achieve any success.

“As an organization, we are beyond just being passionate about this,” Clark said. “We are taking action. There is strength in numbers, and we need people. It costs them nothing, puts them at no risk and there is no downside to getting involved with”

“We want to help the independent O&P continue to operate and treat patients the way that they should and the way that they need to be able to and allow them to do what they do best — focus on patient care,” Ball added. — by Megan Gilbride

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Disclosure: Clark, Ball and Eagen are employed by the OPGA.

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