Preparation is the Best Weapon

LAS VEGAS — The best way to prepare for the regulatory challenges faced by today’s O&P practitioners is to stay current on the continually changing regulations and keep accurate documentation, according to speakers at the American Orthotic & Prosthetic Association National Assembly, here.

Thomas Fise, JD, executive director of the American Orthotic & Prosthetic Association (AOPA), began the session by providing background information on the relationship between O&P professionals and the Office of the Inspector General (OIG). Fise said a flawed 2011 report from the OIG titled “Questionable Billing by Suppliers of Lower Limb Prostheses” made a number of incorrect assumptions about the prosthetic referral and care process. The OIG report, which covered 2005 to 2010, claimed the number of patients receiving prosthetic care remained flat, but the cost of care billed to Medicare increased.

Flawed studies led to confusion, conflict

Among the report’s conclusions, the OIG stated $43 million of fraudulent cases were billed to Medicare as “split claims,” which OIG said showed prosthetists were ordering two prostheses for one limb. Fise said the assumptions made by Medicare show a misunderstanding of the prosthetic profession; submitting two claims for an amputee with two amputations is “perfectly legal” and placing these claims on the same day is typical for prosthetic providers. The report also claimed $61 million worth of fraudulent cases were billed to Medicare for prosthetic care because the cases included no information from the referring physician.

“What they did not understand, first of all, is that when patients need prosthetic care they typically do not go to their physician first, they go to their prosthetist first; that most physicians are not fully versed in all the specifics of the design fabrication and delivery of prosthetic care; and, even more fundamentally, that for most amputees the referring physician who brought the patient to the prosthetist in the beginning was the surgeon who did the amputation,” Fise said. “That surgeon or referring physician discharges the patient and everyone except OIG knows it is unlikely the patient will have subsequent visits with the surgeon after discharge.”

Thomas Fise, JD

Thomas Fise

Once the OIG report received approval from CMS, it was passed on to recovery audit contractor (RAC) and other contractors who “proceeded to crack down on this ‘fraud’ that wasn’t fraud,” he said.

The second account Fise said has created confusion about the O&P industry and its regulations and requirements is the 2012 report “Medicare Supplier Acquisition Costs for L0631 Back Orthoses.”

“This was the genesis of the off-the-shelf regulations [for orthoses],” he said.

Fise said this report claimed a third of orthotic services were being provided without a fitting, even though a fitting was included in the cost billed to Medicare.

“They looked at large numbers without seeing where the real increases had come from other providers, not certified orthotists,” Fise said. “Turns out the one-third [figure] was not backed by data, but OIG made an estimate based on the responses they got from suppliers, including those who did not respond at all.”

Simple mistakes based on an ignorance of the O&P profession have set the industry up to face confusion and conflict, according to Fise.

‘No silver bullets’

As a result of these studies, RAC audits are a real possibility for many O&P professionals. Joseph McTernan, director of coding and reimbursement services, education and programming for AOPA, said a knowledge of RACs and how they work can aid in preparing for audits. One of the most important things to know, he said, is that RAC auditors work on a commissioned basis. This is different from other auditors, including DME MACs, who are paid a flat fee to process claims.

Joseph McTernan

Joseph McTernan

“They are incentivized and they are highly motivated to come after you and get money,” McTernan said of RAC auditors.

McTernan said O&P professionals also should learn the limits on RAC audits to “make sure they are following their own rules … There are very specific limits” to what an RAC auditor can do. For example, he said, RACs can only file a maximum of 10 claims per tax ID every 45 days. RAC audits also are limited to a 3-year look-back period. McTernan emphasized the importance of appeals. RAC contractors have to report to Congress each year and their statistics must include the number of appeals filed.

“When providers are willing to fight, there is almost a 60% success rate on the provider side … and what we have heard from AOPA members is that [the success rate] is even higher for O&P,” he said.

While McTernan acknowledged that “no silver bullets” exist for avoiding RAC audits, providers can prepare themselves by improving communication with their referring physicians and making sure their practice is well-documented and organized.

“Control what you can control. I cannot say that enough,” he said, adding that patients who are willing to speak on behalf of their orthotists and prosthetists are the best spokespeople.

“There simply is no better advocate for you than an angry patient,” he said.


Reducing claims level risk

For prepayment reviews at the administrative law judge level, Mitchell Dobson, CPO, FAAOP, recommended creating a one-sentence summary of the appeal.

“Have a document from the record to support each of your points,” he said, adding that an organizational system such as using colored highlighters can help one find relevant supporting documents more quickly during an administrative law judge (ALJ) review.

Another important point, Dobson said, is to address only the reason for the denial without getting distracted by other issues. Learn the policy that will be referenced and stay on track.

Prior authorization predictions

Devon Bernard, assistant director of coding and reimbursement services, education and programming for AOPA, said prior authorization will cause business as usual in the O&P world to change. A final rule is not expected to be published until 2015, but under current criteria, 89 prosthetic services acknowledged by CMS are eligible for prior authorization.

“Those 89 codes are pretty much every single prosthetic code that is out there. That would mean that every prosthetic service that you wanted to bill [Medicare] for, you would have to have prior authorization for,” Bernard said.

So far no orthotic codes have made the list, Bernard said.

A few issues make the proposed rule confusing and difficult to deal with. The first is that the program could be implemented nationally or locally, so rules could be the same across the board, or could differ by state or local area; prior authorization is not a guarantee that CMS will pay for the product or service; and the decision limit is 10 days, which Bernard said AOPA officials would like to see shortened to five.

Bernard said a prior authorization request can be re-submitted an unlimited number of times if it is denied; however, all claims will be denied if they are submitted straight to Medicare in an attempt to bypass prior authorization approval.

Orthotic codes and regulations

David McGill, vice president of reimbursement and compliance for Össur, said CMS regulations regarding “off-the-shelf” orthoses have changed a number of times and can probably be expected to change again. Regulations regarding competitive bidding for off-the-shelf (OTS) orthoses – defined as orthoses that require “minimal self-adjustment” – changed in 2007, 2012 and 2013. McGill said although AOPA provided 500 pages of detailed comments including clinical research which explained why many of these items require custom fitting from a professional, the final list “provided no substantive response to any of AOPA’s comments.”

David McGill

David McGill

Right now, McGill said there are 32 OTS codes and 29 custom-fit-only codes. Additionally, a third list includes 23 items that can include OTS items which have a custom fit “mate.”

“We have custom fit and off-the-shelf codes sitting side by side, describing the same devices … but now they are being paid the same amount,” McGill said the codes describing OTS orthoses will “ultimately be rolled into competitive bidding. And when those off-the-shelf codes get rolled into competitive bidding … fee schedules are going to drop.”

McGill predicted – emphasizing that this was his own estimate, not AOPA’s – that based upon results from the initial rounds of competitive bidding that he would not be surprised to see off-the-shelf orthosis reimbursements drop by 20% to 35% when these items become part of the competitive bidding program. Additionally, two new K codes were created for custom fit items.

AOPA has a number of concerns about the proposed rule, and McGill listed four changes AOPA believes need to be made before the proposed rule is implemented:

  • The definition of “minimal self-adjustment,” a requirement for an item to be classified as an OTS orthosis, needs to revert to its original description as an item that is adjusted by the patient only as opposed to an orthotist, certified fitter or other professional.
  • More rules should be included to protect beneficiaries, and items that patients will not be able to safely put on themselves correctly should be removed. “We need to revise that list in order to protect people from themselves because these items are not all off-the-shelf,” McGill said.
  • The list of appropriate supervisors should be expanded to include certified orthotic fitters and assistants. “Those people have always been part of the delivery chain of these kinds of items. They need to continue to be part of that chain. That is what they are trained to do and what they are qualified to do,” McGill said.
  • Medicare needs to receive and address “appropriate stakeholder input” before implementing the proposed rule.

“They are doing this in a way that effectively fundamentally changes how health care is delivered, and they are doing it without any opportunity to get input from organizations like AOPA and all of you who are practicing and dealing with these issues every day.”

McGill said looking for feedback from the O&P field will allow CMS to “construct rules that make some sense in light of how the world [of O&P care] actually works.” — by Amanda Alexander

For more information:
Dobson M. This just in – OIG, audits, ALJ delays and more. Presented at: American Orthotic & Prosthetic Association National Assembly. Sept. 4-7, 2014. Las Vegas.

Disclosures: Bernard, Dobson, Fise, McGill and McTernan have no relevant financial disclosures.

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