September/ October 2018 O&P Visionary

Ralph W. Nobbe, CPO

Experienced O&P businessman and clinician advocates for O&P licensure, prompt pay laws, and clinician volunteerism

Recently, I received an email request from AOPA Executive Director Tom Fise, JD, with the subject line, “Would you consider?” He was giving me the opportunity to “state my piece” and “wave the wand of change” for O&P. Hmmmm … I was not sure whether I was flattered for being considered or insulted since my certification number is frequently one of the lowest on sign-in sheets and I am now considered an “old timer.”

Following a 30-plus-year career as a second-generation O&P practitioner, I have witnessed some dramatic changes in health care and O&P. As I reflect back on my career, I can recall my original entry into the field and very first patient encounter. Up until that patient encounter, I had worked during vacations, after school, and summers for my father, Erwin A. Nobbe, CPO(E). Just like other O&P professionals who grew up in and around the industry, I did some fabrication and “other tasks as may be assigned”—usually to keep me busy and out of trouble.

While exploring careers, I was not entirely convinced that O&P was the best choice. My first venture was participation in an outreach trip organized through the O&P program at Cerritos College. The O&P students travelled to a clinic in Calexico over a three-day weekend under the supervision of Robert Hinchberger, CPO(E). I recall there were five or six of us who made the trip.

One of the patients presented into the clinic with a knee-ankle-foot orthosis (KAFO) that badly needed repairs. She was elderly and had travelled quite some distance, spoke no English, and came in with the KAFO under her arm in a wheelchair. I was selected to do the repairs because I had experience using a long arm patcher, knew how to sew leather, and could speak some Spanish. I was able to complete the repairs, then she expressed her gratitude profusely and left—walking out. “OK, that was cool,” I thought.

The KAFO patient returned the very next day with her entire family. They had travelled about two hours and brought enough food to feed at least 30 people. They were not satisfied until we had all eaten so much we could not move. My decision was made: I was going into O&P.

Over the years, I have experienced similar instances of grateful patients, parents, and families. I have attended weddings, graduations, and, more recently, funerals. I have no doubt that all orthotists and prosthetists have similar stories to tell.

However, with those positive experiences also come the business and administrative frustrations of modern health care. In the early days, life was simple: Patients presented with a prescription and paid, or their insurance paid when they received a bill. As time marched along, a new alphabet soup of acronyms was created: HMOs, PPOs, EPOs, ERISA, HSA, HDHP, and ACOs—as well as third-party financing options. All served to reduce our net reimbursements and increase administrative processing costs.

All of the major payors—Medicare, Medicaid, the U.S. Department of Veterans Affairs (VA), and private insurers—engaged in an increasing documentation demand in active pursuit of cost control, limiting fraud and abuse, and reducing “excessive” utilization. We dealt with the Health Insurance Portability and Accountability Act, K levels, outcome measures, prior authorization, recovery audit contractor audits, prepay audits, retrospective denials, and outside third-party reviewers who “recommend” a reduced reimbursement. These documentation demands requested corroborating documentation from physicians and letters of medical necessity. Our own O&P notes held no value because we had a vested interest in the outcome of the claim. O&P was always a ripe target to pick on as a small, referral-based industry with a very high unit cost of service.

Against this background of O&P, the following is my “wish-list” for the O&P profession:

  1. Licensure would give each individual practitioner standing among the medical community and should be pursued by the professional associations and individual practitioners.
  2. Prompt pay laws should be enacted: If a medical service/device is provided, the device has received prior authorization with preservice medical review, and the patient was eligible on the date of service, that claim should be paid promptly and as agreed, irrespective of the type of insurance.
  3. Recoupment and offsetting payment should be stopped. It creates an accounting nightmare for all involved, and all claims should be subject to the prompt pay requirements.
  4. Practitioner notes and documentation should be recognized. A licensed, credentialed practitioner should be able to document patient-specific needs for a given device following physician prescription/referral. Physician countersignature of the “orthotic/prosthetic treatment plan” should provide adequate documentation and would place our service delivery requirements on par with other referral-based providers of medical care.
  5. Payment for O&P services by all paying agents, most specifically Medicare, VA, and Medicaid, should only be made to accredited facilities with appropriately credentialed staff.
  6. The O&P industry’s alphabet soup of representative groups leads to lots of confusion. The industry numbers are simply too small to have so many entities with slightly differing messages. Patients will be best served with unified messaging delivered in a consistent manner.
  7. Participation should be a priority. Every practitioner, as part of their mandatory continuing education, should serve a defined number of hours in a volunteer capacity within the industry organizations. Serve on a committee, do a presentation, go visit your legislators, meet with other associations. Attend the AOPA Policy Forum.

The O&P industry has an easy story to tell. Go tell it.

Ralph W. Nobbe, CPO, is president of Nobbe Orthopedics Inc. in Santa Barbara, California.