Spring 2019 O&P Visionary: Eve Lee, MBA, CAE, Executive Director of AOPA

The recent indictments in fraudulent Medicare schemes are a step in the right direction…

On March 28, 2019, AOPA released a statement strongly criticizing the use of lead generation marketing to deliver orthotic devices to patients covered by Medicare or other types of insurance. This practice puts patients at risk as it does not provide clinical care by a qualified orthotic professional and could lead to providing medically unnecessary orthoses with no instruction on proper fitting, care, or use.

On April 9, less than two weeks later, the U.S. Department of Justice (DOJ) announced multiple indictments against 24 individuals responsible for more than $1.2 billion in losses to the Medicare program through fraudulent schemes involving the use of lead generation marketing to deliver orthoses that were not medically necessary or not wanted by the beneficiary. Simultaneously, CMS announced the immediate suspension of Medicare payments to 130 Medicare-enrolled durable medical equipment suppliers suspected of participating in the scheme and responsible for more than $1.7 billion in Medicare claims and more than $900 million in Medicare reimbursement.

AOPA is highly encouraged by both the DOJ indictments and the administrative action taken by CMS. We are hopeful that this sweeping action will drive this criminally negligent activity out of the orthotic and prosthetic marketplace.

AOPA first expressed concern about potential fraud and abuse involving off-the-shelf (OTS) orthoses when CMS identified a complete set of OTS codes that, according to its own policy, required little to no fitting by properly certified or licensed orthotic professionals to deliver and bill to Medicare. We have continued to voice our concern at every opportunity.

Most recently, AOPA has pursued legislation that will ensure that Medicare patients continue to have access to clinically appropriate orthotic care delivered by properly educated, certified, and/or licensed professionals. AOPA, with the support of its O&P Alliance partners, is preparing—the Medicare Orthotics and Prosthetics Patient-Centered Care Act—which contains several provisions that would further guarantee that criminal elements such as those uncovered by DOJ will no longer be able to use OTS orthoses to generate illegal profits through exploitation of the Medicare program and its beneficiaries. AOPA is currently meeting with key members of Congress to discuss potential sponsorship. During the 2019 AOPA Policy Forum, which took place in Washington, DC, May 7-8, AOPA members met with members of Congress to educate them on the issue and ask them to take action that protects patients.

Eve Lee, MBA, CAE, is executive director of AOPA.