A major new study commissioned by the Amputee Coalition and conducted by Dr. Allen Dobson, health economist and former director of the Office of Research at CMS shows that the Medicare program pays more over the long-term in most cases when Medicare patients are not provided with replacement lower limbs, spinal orthotics, and hip/knee/ankle orthotics.
Patients who received orthotic or prosthetic services have lower or comparable Medicare costs than patients who need, but do not receive, these services. Learn more.
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- The Amputee Coalition is the nation’s leading organization on limb loss, dedicated to enhancing the quality of life for amputees and their families, improving patient care and preventing limb loss. Find support groups, limb loss events, and other resources.
- Limb Loss Resource Center
- Inspirational Stories
- Limb Loss Prevention
- Financial Assistance
- Diabetes Resources
- The Jordan Thomas Foundation provides children affected by limb loss with the prostheses they need throughout childhood and adolescence and serves as a caring resource, advocate and support system for the children and their families
- Insurance Coverage and Reimbursement
“Everyone’s experience with limb loss and limb difference is unique. However, access to medically appropriate devices can dramatically change that experience, providing an avenue for a more active, engaged life in the community and the workplace. This study offers national data that provides support for the need for access to care — as well as pointing out the opportunity to further explore the impact prosthetic devices can have, both financially and personally.”
President & CEO, Amputee Coalition
Share your O&P Story
We welcome you to share your story of how orthotics and/or prosthetics have improved your quality of life, and tell us about issues you have had with reimbursement, and how you eventually obtained coverage. Please share here.
On December 29th 2015, the Centers for Medicare and Medicaid Services (CMS) released the final rule regarding Medicare prior authorization of certain DMEPOS, including most lower limb prostheses. The final rule will be implemented February 29, 2016. The concern with prior authorization of prostheses is that it will critically delay timely access to the provision of prosthetic devices that are crucial to the rehabilitation needs of Medicare beneficiaries. While Medicare expressed concern about appropriate timeframes for decisions, timeframes are yet to be established.
The rule is in place beginning February 29, but we have some indications that: (1) CMS is more likely to take an incremental approach—regional steps with a limited number of devices seems more likely than a national rollout on all prosthetics; (2) CMS may be interested to see how the draft LCD follow-up proceeds before rolling out prosthetic Prior Authorization; (3) they pledge to take steps to avoid delay in patient access to care, and to try to minimize, if not eliminate the prospect that there are post-payment audits on medical necessity issues after a Prior Authorization has been secured, which could push the date for implementation of Prior Authorization for prosthetics 6 -12 months later.
While AOPA is still concerned that the prior authorization process will delay patient access to prosthetic devices, providers will have more time to prepare than initially expected, and should be able to comply with this new rule by the time it affects patients. Since prior authorization is premised explicitly on the need to control unnecessary or excessive utilization, clearly those classes of devices showing -40+% reduction in utilization since 2010 (K3 and K4 advanced prosthetics) should not be on the list of codes subject to prior authorization.
LCD Lower Limb Draft Policy
WITHIN A MATTER OF DAYS of the July 16, 2015 draft policy issued by the DME MACs, AOPA mobilized its members, allies, and advisers to work on multiple strategies to have this ill-conceived policy rescinded. The O&P Community, the amputee community and the leadership of the groups that represent them, quickly banded together in a coordinated effort to make sure our O&P voices were heard. AOPA created an action plan to guide our overall strategy.
Prominent O&P researchers whose work was cited in the LCD sent a letter to the contractors stating “As CMS has used our works in the preparation of this ill-conceived proposal, we are led to question why we, as health care experts in this field, were not consulted. The proposed changes … in our expert opinion, would diminish both the quality and access to prosthetic care across our nation. We, as the experts cited in this document, wish to go on record as strongly opposing the draft [rule].” Read the full letter.
On November 2, 2015, the White House issued a statement that the proposal would not be finalized. (Read the initial White House petition). CMS would be convening a workgroup of clinicians, researchers, and policy specialists. The immediate concern is that this is NOT a rescission of the Draft LCD. Some might see this as following a too frequent government step of “kicking the can down the road.” AOPA’s leadership and regulatory specialists will review ALL government and contractor communications as they arise, and provide a further analysis once that in-depth review is complete. Read the White House statement, CMS statement, and the DMEMAC statements – Jurisdiction A, Jurisdiction B, Jurisdiction C, Jurisdiction D. Read AOPA’s full statement on the White House announcement.
On April 28, 2016 the House Oversight and Government Reform Committee released a letter it has initiated to HHS Secretary Sylvia Mathews Burwell, criticizing the prosthetic LCD efforts of CMS and its contractors, and launching an oversight inquiry with a request for a substantial collection of documents.
O&P professionals, students, and patients visited Capitol Hill April 26-27 to meet with legislators to advocate for fair treatment of O&P providers and patients. One clinician met with Senate Majority Leader, Mitch McConnell (R-KY), who then authorized a letter to CMS Acting Administrator, Andy Slavitt regarding the 2015 LCD Policy, its status, and the workgroup that has been assembled to evaluate CMS’ O&P policy. Read the letter.
In June 2016, the Senate Appropriations Committee Report incorporated recommendations to CMS on the Draft LCD. This is an important directive to CMS, essentially that in light of reductions in Medicare prosthetic spend over 2012-2014, there seems no necessity for intervention to change the LCD, and instructing CMS to consult with clinicians, patients and prosthetist groups before releasing any new or revised version of the LCD. The following language was included:
“The Committee recognizes that Medicare payments for all prosthetics, and especially the newer advanced technologies, have declined over each of the years 2010-2014. The committee encourages CMS to consult broadly with clinicians, patient groups, and the prosthetics field regarding revisions to the draft Local Coverage Determination, prior to publishing an updated draft policy for public comment.”
Orthotics (Back Braces)
There have been reports of fraudulent activity regarding 2 back braces commonly prescribed to Medicare patients (L0631 and L0637). If you review the charts and graphs below, you can clearly see that these codes are not being provided by certified orthotists, but medical suppliers and other health care providers, who are not qualified to provide these braces.
- Who is Billing Medicare for these Codes?
- Medicare Utilization Comparison
- O&P vs. All Other Providers
An Example of the LCD Draft Policy Influencing Private Insurers
In a policy that seems to be a result of the LCD Proposal, United Health Care deems vacuum pumps for residual limb volume management “…unproven and not medically necessary” as of October 1, 2015. Read the policy here. The Wall Street Journal covered the issue in this article about the draft LCD, and there is also an article in the Minnesota Star Tribune.
AOPA is pursuing a two part strategy: (a) AOPA partnered with a congressional representative in UHC’s state, who contacted UHC requesting that they set up a high level meeting with AOPA reps; and (b) AOPA has joined in a letter of objection to the policy from the O&P Alliance, together with the Amputee Coalition, challenging the assertion that there is no scientific evidence to support this treatment, and seeking a meeting with UHC’s Medical Director. We believe the results can be additive and symbiotic, not divisive, in bringing attention to the problem from multiple directions. Read UHC’s disappointing response then the rebuttal from the O&P Alliance.
Cigna has adopted the same policy. Read the letter from the O&P Alliance and the Amputee Coalition.
We promise to continue to keep you posted on the UHC issues, but we have also received an early indication about another outgrowth of the commercial sector jumping on the draft LCD as an opportunity for cutbacks–this time from one of the state BCBS plans. We are waiting to see documentation, but if this proves correct, we will again communicate with the insurer AND communicate to CMS (as we did when the UHC policy first arose) underscoring yet again the need for a quick decision to rescind the draft LCD.