Proposed Legislation Would Protect Our Patients

The Center For Medicare and Medicaid Services (CMS) and the American Orthotic and Prosthetic Association (AOPA) are working diligently on two pieces of legislation that will benefit the prosthetics and orthotic field and improve the quality of care for our patients.

The first bill, the Medicare Orthotics and Prosthetics Patient Centered Care Act, will ensure that Medicare beneficiaries receive appropriate, safe, and effective orthotic and prosthetic care, as prescribed by their physician.

The bill would achieve multiple goals. One goal is to restore Congress’s intended meaning of “minimal self-adjustment,” which defined off-the-shelf (OTS) orthoses that may be subject to competitive bidding. Congress intentionally exempted all limb prostheses and most orthoses from competitive bidding because of the clinical nature of custom-fabricated and custom-fit O&P care. However, Congress authorized the Medicare program to competitively bid limited off-the-shelf orthotics, stating that off-the-shelf orthoses are those that “require minimal self-adjustment for appropriate use and do not require expertise in trimming, bending, molding, assembling, or customizing to fit to the individual.” This definition intentionally describes a very small segment of orthotic devices, essentially those found only at retail pharmacies or department stores. However, CMS has used an expanded regulatory definition of minimal self-adjustment, which has resulted in the classification of many orthotic items as off-the-shelf when, in fact, the items require a level of professional care to avoid potential harm. This expanded definition invites potential abuse of the orthotic benefit, as off-the-shelf braces are not subject to CMS quality standards. Ensuring congressional intent on the definition of off-the-shelf will reduce patient risk.

Next, the Medicare O&P Patient Centered Care Act would help preserve access to care by exempting practitioners from having a competitive bidding contract to provide off-the-shelf orthoses to their patients while providing O&P patient care, like the exemption already utilized by physicians. This provision would guarantee patients have access to the full range of orthotic care from one orthotic/prosthetic practitioner rather than requiring patients to visit multiple providers in the case where the treating orthotist or prosthetist does not have a competitive bidding contract. Under this provision, certified clinicians would be able to provide off-the-shelf orthoses, with reimbursement set at the single payment amount as determined by CMS through the competitive bidding process, as to not cost the Medicare program more than it would otherwise spend.

Finally, the new legislation would differentiate O&P Care from durable medical equipment (DME), ensuring proper, safe, and effective patient care. Currently, O&P providers are grouped with DME suppliers even though the provision of DME commodities is much different than that of O&P care. O&P treatment can take years, even decades, given ongoing mobility needs of amputees or impaired patients. O&P care requires extensive follow-up, requiring a clinical relationship between patients and practitioners. Differentiating O&P from DME would allow CMS to create regulations that consider O&P provider education, skill sets, and the ability to work with a patient on custom fitting and fabricating as needed.

The American Orthotic and Prosthetic Association is working with a diverse group of legislators including Representatives G.T. Thompson ( R-Pennsylvania ) and Mike Thompson ( D-California ) in the House of Representatives and Senator Mark Warner ( D-Virginia ) and others in the Senate to ensure bipartisan input and support of the bill.

Source: The O&P Almanac