The Magazine for the Orthotics & Prosthetics Profession
N OV E M B E R 2019
Guidelines for Holiday Gift-Giving P.18
New Tools for Detecting and Preventing Diabetic Ulcers P.30
Leveraging Machine Learning To Advance O&P Technologies
ONE STEP AHEAD of Veterans' Needs EXCLUSIVE INTERVIEW WITH THE VA'S NATIONAL DIRECTOR OF O&P CLINICAL SERVICES
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WWW.AOPANET.ORG
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This Just In: Proposed Changes to Physician Self-Referral and Federal Antikickback Regulations P.22 E! QU IZ M EARN
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contents
NOVE M B E R 2019 | VOL. 68, NO. 11
COVER STORY
FEATURES
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24 | One Step Ahead of Veterans’ Needs In this exclusive interview, M. Jason Highsmith, PhD, PT, DPT, CP, FAAOP, shares his insights and experiences as national director of orthotic and prosthetic clinical services at the U.S. Department of Veterans Affairs (VA). Find out how the VA is prioritizing optimal O&P care for veterans, updating practice guidelines, embracing new technologies, delving into research in areas of greatest relevance to the veteran population, and partnering with private O&P practices to meet the needs of the entire veteran community.
22 | This Just In
Modernizing the Ethics Rules In an effort to ease unnecessary regulatory burdens on healthcare providers in the interest of facilitating the delivery of efficient, high-quality healthcare, CMS has issued a proposed rule that would significantly alter the Stark physician self-referral regulations and the federal antikickback regulations. Learn about the exceptions and new guidance included in the proposal.
30 | Damage Control Patients who have diabetes are at risk of developing foot ulcers that may get infected and cause severe damage to tissue and bone. Some pedorthic, orthotic, and prosthetic professionals are leveraging new tools and technology to prevent ulcers and promote overall foot health in addition to fitting patients with more traditional therapeutic shoes and inserts. By Christine Umbrell
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contents
PRINCIPAL INVESTIGATOR Patrick M. Pilarski, PhD............................ 36 Meet a Canadian professor who applies his expertise in artificial intelligence and machine learning to advance the science of orthotics and prosthetics.
DEPARTMENTS Views From AOPA Leadership......... 6 Jim Weber, MBA, highlights AOPA’s accomplishments and priorities
AOPA Contacts.......................................... 8 How to reach staff
Numbers...................................................... 10 At-a-glance statistics and data
Happenings................................................12
Research, updates, and industry news
People & Places........................................16 Transitions in the profession
COLUMNS Reimbursement Page.......................... 18
Out With the Old
Tips on the new Medicare ID cards, gift-giving, participation status, and more
P.12 AOPA News...............................................43
CE Opportunity to earn up to two CE credits by taking the online quiz.
AOPA meetings, announcements, member benefits, and more
CREDITS
O&P PAC Update .................................. 44 Member Spotlight................................ 40 n
n
Blue Ridge Prosthetics & Orthotics PEL
Careers.........................................................45 Professional opportunities
Marketplace............................................. 46 Calendar..................................................... 49 Upcoming meetings and events
Ad Index....................................................... 51 Ask AOPA...................................................52 Guidelines for out-of-pocket payments, waiving copays, and more
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NIGHT MODE
OU R F U L L L I N E O F VA LV ES . N OW AVAI LAB L E I N M I D NI GH T B L ACK .
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VIEWS FROM AOPA LEADERSHIP
Specialists in delivering superior treatments and outcomes to patients with limb loss and limb impairment.
Proud of Our Progress
T
WO YEARS AGO, AS I began my first term as president of AOPA, I concluded
this column with these words: “Change is constant, the future is now, and we must continue to collaboratively pursue advocacy, research, and education to improve patient access to quality orthotic and prosthetic care.” Looking back, we would all likely agree, change is constant. A very big change for AOPA in 2019 is the change in leadership. We have aggressively doubled down on our focus on our mission, AOPA’s strategic plan, committee structure and purpose, and AOPA staff under the very capable guidance of our new executive director, Eve Lee, MBA, CAE. This change in leadership has sparked a renewed focus on advancing access to care for our patients. After getting a key aspect of our legislation passed in 2018, the recognition of orthotists’ and prosthetists’ notes as part of the medical record, we took a step back this year and reworked the language we used, making it more focused on the impact to our patients. To that end, Justin Beland, AOPA’s new director of government affairs, and Teri Kuffel, JD, AOPA’s Advocacy Pillar chair, are leading the effort to get the Medicare O&P Patient-Centered Care Act introduced and passed. We also are focused on passing the Wounded Warriors Workforce Enhancement Act, which will help address the impending shortage of O&P professionals. Collaboration is vital as AOPA works with our O&P Alliance partners and industry leaders to advance these critical pieces of legislation for our members and, most importantly, our patients. Our research initiatives have advanced under the capable leadership of David Boone, BSPO, MPH, PhD, AOPA’s Research Pillar chair, with the coordination efforts of Ashlie White, MA, AOPA’s director of strategic alliances. It is important to understand that research isn’t just about developing the next great orthosis or prosthesis; there also are efforts underway to generate interest in population studies, healthcare disparity and inequity studies, and research focused on the economic value of O&P. AOPA continues to support O&P research efforts through direct funding and the implementation of projects through the Center for O&P Learning and our two newer initiatives, Prosthetics 2020 and Orthotics 2020. These programs support the generation of an evidence base that shows the efficacy and cost effectiveness of the clinical services you provide. AOPA has funded $500,000 in research to support the profession this fiscal year. And we wouldn’t be here without AOPA’s education initiatives led by Traci Dralle, CFM, Education Pillar chair, and Tina Carlson, AOPA’s chief operating officer. The AOPA National Assembly is certainly a large part of the education portfolio, but our experts provide numerous educational opportunities throughout the year, including the Coding and Billing Seminars, the monthly webinars, and AOPAversity, the on-demand educational opportunity. The staff works hard to keep these opportunities relevant to you, our members. I am very proud of the efforts of our committed board and committee members and our very capable AOPA staff. They have met the constant change in our profession with hard work and a positive outlook for our future, which is now in the very capable hands of our incoming AOPA president, Jeffrey Lutz, CPO. Thank you for all you do for the profession and your patients, thank you for your support over the past two years, and thank you for this opportunity to serve. Jim Weber, MBA, is president of AOPA and will take on a new role as immediate past president in December.
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Board of Directors OFFICERS President Jim Weber, MBA Prosthetic & Orthotic Care Inc., St. Louis, MO President-Elect Jeffrey Lutz, CPO Hanger Clinic, Lafayette, LA Vice President Traci Dralle, CFM Fillauer Companies, Chattanooga, TN Immediate Past President Michael Oros, CPO, LPO, FAAOP Scheck and Siress O&P Inc., Oakbrook Terrace, IL Treasurer Jeffrey M. Brandt, CPO Ability Prosthetics & Orthotics Inc., Exton, PA Executive Director/Secretary Eve Lee, MBA, CAE AOPA, Alexandria, VA DIRECTORS David A. Boone, BSPO, MPH, PhD Orthocare Innovations LLC, Edmonds, WA J. Douglas Call, CP Virginia Prosthetics & Orthotics Inc., Roanoke, VA Mitchell Dobson, CPO, FAAOP Hanger Clinic, Grain Valley, MO Elizabeth Ginzel, MHA, CPO NovaCare P&O, Fort Worth, TX Kimberly Hanson, CPRH Ottobock, Austin, TX Teri Kuffel, JD Arise Orthotics & Prosthetics Inc., Spring Lake Park, MN Rick Riley Thuasne USA, Bakersfield, CA Linda M. Wise WillowWood, Mount Sterling, OH
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AOPA CONTACTS
American Orthotic & Prosthetic Association (AOPA) 330 John Carlyle St., Ste. 200, Alexandria, VA 22314 AOPA Main Number: 571/431-0876 AOPA Fax: 571/431-0899 www.AOPAnet.org
Publisher Eve Lee, MBA, CAE Editorial Management Content Communicators LLC Advertising Sales RH Media LLC
Our Mission Statement Through advocacy, research, and education, AOPA improves patient access to quality orthotic and prosthetic care.
Our Core Objectives AOPA has three core objectives—Protect, Promote, and Provide. These core objectives establish the foundation of the strategic business plan. AOPA encourages members to participate with our efforts to ensure these objectives are met.
EXECUTIVE OFFICES
REIMBURSEMENT SERVICES
Eve Lee, MBA, CAE, executive director, 571/431-0807, elee@AOPAnet.org
Joe McTernan, director of coding and reimbursement services, education, and programming, 571/431-0811, jmcternan@AOPAnet.org
Tina Carlson, CMP, chief operating officer, 571/431-0808, tcarlson@AOPAnet.org GOVERNMENT AFFAIRS Justin Beland, director of government affairs, 571/ 431-0814, jbeland@AOPAnet.org COMMUNICATIONS, MEMBERSHIP & MEETINGS
Reimbursement/Coding: 571/431-0833, www.LCodeSearch.com
STRATEGIC ALLIANCES
Joy Burwell, director of communications and marketing, 571/431-0817, jburwell@AOPAnet.org
Ashlie White, MA, director of strategic alliances, 571/431-0812, awhite@AOPAnet.org
Betty Leppin, manager of member services and operations, 571/431-0810, bleppin@AOPAnet.org
O&P ALMANAC
Kelly O’Neill, CEM, manager of membership and meetings, 571/431-0852, kelly.oneill@AOPAnet.org Ryan Gleeson, CMP, assistant manager of meetings, 571/431-0836, rgleeson@AOPAnet.org Yelena Mazur, communications specialist, 571/431-0835, ymazur@AOPAnet.org Kristen Bean, membership and meetings coordinator, 571/431-0876, kbean@AOPAnet.org AOPA Bookstore: 571/431-0876 8
Devon Bernard, assistant director of coding and reimbursement services, education, and programming, 571/431-0854, dbernard@AOPAnet.org
NOVEMBER 2019 | O&P ALMANAC
Eve Lee, MBA, CAE, executive director/publisher, 571/431-0807, elee@AOPAnet.org
Design & Production Marinoff Design LLC Printing Sheridan SUBSCRIBE O&P Almanac (ISSN: 1061-4621) is published monthly by the American Orthotic & Prosthetic Association, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314. To subscribe, contact 571/431-0876, fax 571/431-0899, or email ymazur@AOPAnet.org. Yearly subscription rates: $59 domestic, $99 foreign. All foreign subscriptions must be prepaid in U.S. currency, and payment should come from a U.S. affiliate bank. A $35 processing fee must be added for non-affiliate bank checks. O&P Almanac does not issue refunds. Periodical postage paid at Alexandria, VA, and additional mailing offices. ADDRESS CHANGES POSTMASTER: Send address changes to: O&P Almanac, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314. Copyright © 2019 American Orthotic and Prosthetic Association. All rights reserved. This publication may not be copied in part or in whole without written permission from the publisher. The opinions expressed by authors do not necessarily reflect the official views of AOPA, nor does the association necessarily endorse products shown in the O&P Almanac. The O&P Almanac is not responsible for returning any unsolicited materials. All letters, press releases, announcements, and articles submitted to the O&P Almanac may be edited for space and content. The magazine is meant to provide accurate, authoritative information about the subject matter covered. It is provided and disseminated with the understanding that the publisher is not engaged in rendering legal or other professional services. If legal advice and/or expert assistance is required, a competent professional should be consulted.
Josephine Rossi, editor, 703/662-5828, jrossi@contentcommunicators.com Catherine Marinoff, art director, 786/252-1667, catherine@marinoffdesign.com Bob Heiman, director of sales, 856/673-4000, bob.rhmedia@comcast.net Christine Umbrell, editorial/production associate and contributing writer, 703/6625828, cumbrell@contentcommunicators.com
Advertise With Us! Reach out to AOPA’s membership and more than 11,400 subscribers. Engage the profession today. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net. Visit bit.ly/almanac19 for advertising options!
Spinal Technology Offers an App for Practitioners
With this app, practitioners can take 3D scans, include images to denote anatomical landmarks, then write comments and instructions on the images. Powered by TechMed 3D software, our app combines all images and order form documentation into one secure electronic file.
The SpinalTech3D™ Scan app is designed to work seamlessly with an Apple iPad® and Structure Sensor.
Our SpinalTech3D™ Scan app refines the process of ordering custom spinal orthoses from Spinal Technology by electronically integrating scans, images, and practitioner instructions into our custom spinal and scoliosis orthometry forms. With this app, practitioners can take 3D scans, include images, denote anatomical landmarks, write comments and instructions on the images. Powered by TechMed 3D software, our app combines all images and documentation into one secure electronic file, which is emailed directly to Spinal Technology. When the file is received in-house, we use our proprietary software to modify the scan based on the patient’s information and the brace design selected. The modified 3D model is fine-tuned and uploaded into one of our six carvers to produce a positive mold of the patient’s torso: used to fabricate a precise custom orthosis.
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NUMBERS
While many individuals living with diabetes develop costly related health problems, including amputations, some new statistics are encouraging
DIABETES IN THE U.S.
Millions of Americans are knowingly or unknowingly living with diabetes. Many of these individuals develop complications— such as foot ulcers and infections—that send them to the Emergency Department (ED) of their local hospitals.
30.3 Million 23.1 Million
Number of people who have diabetes in the United States
Number of people with diagnosed cases
SOARING COSTS OF DIABETES
$245 Billion
Total medical costs and lost work and wages, per year, for people with diagnosed diabetes
2X
Medical costs for people with diabetes are more than twice as high as for people without diabetes
4-10 Percent
5-24 Percent
>80 Percent
Percentage of people with diabetes who develop foot ulcers
Percentage of foot ulcers that lead to limb amputation within six to 18 months of initial evaluation
Percentage of lower-extremity amputations that begin with foot ulcers
Rate of ED Visits Among Individuals With Diabetes, Per 1,000 Persons Ages 45-64 69
Ages 65-74 114
Ages 75 and Older 164
ED Visits That Lead to Hospital Admissions ED Visitors 28% With Diabetes ED Visitors 17% Without Diabetes
Source: “Emergency Department Visits By Patients Aged 45 and Over With Diabetes,” National Center for Health Statistics, CDC.
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Number of people with undiagnosed cases
REASON FOR HOPE: U.S. DIABETES RATES DECLINING
1.7 Million
Number of new diabetes cases diagnosed in 2008
FOOT ULCERS
7.2 Million
NOVEMBER 2019 | O&P ALMANAC
1.3 Million
Number of new diabetes cases diagnosed in 2017
8.2
PER 100 ADULTS Number of adults living with diagnosed diabetes in 2009
8.0
PER 100 ADULTS Number of adults living with diagnosed diabetes in 2017
SOURCES: Centers for Disease Control and Prevention; “Emergency Department Visits By Patients Aged 45 and Over With Diabetes,” National Center for Health Statistics, CDC; mayoclinic.org; American Diabetes Association.
Diabetes Complications
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Happenings RESEARCH ROUNDUP
Virginia Tech Researchers To Develop Smart Prosthetic Sockets
From left, the research team includes aerospace engineering sophomore Destiny Mason, Associate Professor Michael Philen, PhD, mechanical engineering junior Trevor LeMaster (front), Professor Michael Madigan, PhD, and aerospace engineering PhD candidate Carson Squibb. The ultimate goal is to develop a smart prosthetic socket integrating fluidic matrix composites, which have been successfully demonstrated in applications in aerospace structures as well as other advanced uses. Wafers of the composite materials can achieve an increase in volume when pressurized, exhibit changes in stiffness, and be fabricated into a variety of shapes and configurations, according to the researchers. They believe the materials will be successful in accommodating limb volume loss and helping maintain a comfortable fit.
PHOTO: Virgina Tech
The National Science Foundation has awarded a $400,000 grant to researchers at the Virginia Tech College of Engineering to study residual limb volume loss and develop smart prosthetic sockets. The goal is to identify solutions to improve comfort and performance in prostheses. The project will be led by Michael Philen, PhD, a professor in the Department of Aerospace and Ocean Engineering, and Michael Madigan, PhD, in the Department of Industrial and Systems Engineering, who will collaborate with Brian Kaluf, CP, clinical outcome and research director at Ability Prosthetics and Orthotics. The grant spans three years, during which the team will develop and study techniques to accurately measure residual limb volume change and deformation over the course of a day. They also will study changes in the fit of the prosthetic socket. The research is intended to assist the Virginia Tech team in designing a smart socket that would allow amputees to change the volume of their socket as their limb shrinks in volume throughout the day. The team will track strains on the residual limb during daily activities using digital image correlation and a clear diagnostic socket. To aid in this effort, the researchers are developing a high-precision laser scanning system to measure shape and volume of limb before and after engaging in activities.
Texas Researchers Leverage Hand AI To Improve Prosthetic Control
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data recorded from eight people making 15 hand gestures, individuals with upper limb loss were able to realize a variety of hand movements, according to the researchers. “Our solution uses a novel deep convolutional neural network to eschew the feature-engineering step,” explained Jafarzadeh. “Removing the feature extraction and feature description is an important step toward the paradigm of end-to-end optimization. Our results are a solid starting point to begin designing more sophisticated prosthetic hands.” The research can be applied to other types of prosthetic devices with only minor changes, according to the UT-Dallas team. The team presented its research at the 2019 IEEE International Symposium on Measurement and Control in Robotics in September.
IMAGE: Getty Images
Scientists at the University of Texas at Dallas (UT-Dallas) are developing a deep-learning approach to control prosthetic hands. Their approach leverages electromyography (EMG) signals using an advanced form of artificial intelligence. The UT-Dallas team, led by Yonas Tadesse, PhD, an associate professor of mechanical engineering, and Mohsen Jafarzadeh, a researcher in the Department of Electrical Engineering, has developed a faster system that does not require preprocessing results for control. The EMG-based control system leverages the prosthesis user’s personal data to retrain the system based on the user’s request. Using
HAPPENINGS
EDUCATION INFORMATION
Kennesaw State University To Offer Master’s in O&P
The University System of Georgia Board of Regents has approved a master of science in prosthetics and orthotics program at Kennesaw State University (KSU), beginning in fall 2020. The program will be housed in the Department of Exercise Science and Sport Management in the WellStar College of Health and Human Services. The KSU program will be the only
O&P master’s program in the state, and one of 13 in the nation. Previously, Georgia Tech hosted a master’s in O&P program, but that program was shuttered during a reorganization, with the last class of O&P students graduating from Georgia Tech in May of 2019. “The WellStar College at KSU has a rich history of educating health practitioners while also fostering impactful collaborations between industry partners and the university’s academic units,” said KSU President Pamela Whitten. “This graduate program has the potential to grow into a marquee program and positively impact not only the state, but the broader region, through robust research and service opportunities.”
RESOURCE CENTRAL
ABC Publishes Statement on Telehealth in O&P The American Board for Certification in Orthotics, Prosthetics, and Pedorthics (ABC) has published the “ABC Statement on Telehealth in Orthotics & Prosthetics,” available on the organization’s website. Noting the increasing availability and use of computer and smartphone technologies, as well as the need for increased access to healthcare among consumers in rural or underserved areas, ABC “recognizes the use of telehealth as a method by which some elements of O&P care may be delivered and how that may enhance patient-practitioner collaborations, improve health outcomes, and increase access to care when appropriately used as a component of a patient’s care,” according to the statement.
O&P HONORS
BOC Announces Certificant Award Program
www.bocusa.org
The Board of Certification/ Accreditation (BOC) has established the Certificant of the Year, a new award honoring its valued credential holders. The award will recognize one individual per year for outstanding achievements in service, research, and outreach. The BOC Certificant of the Year Award will distinguish one individual in good standing in any of BOC’s six certification areas: DME Specialist, Mastectomy Fitter, Orthotic Fitter, Orthotist, Pedorthist, or Prosthetist. Nominees must demonstrate exceptional service to patients, notable achievements in research, and commitment to giving back to the community and/or outreach to developing countries or other underserved areas. “There are many certified professionals doing amazing things in their community and professional field with limited recognition,” explained BOC’s credentialing director, Matthew Gruskin, MBA, BOCO, BOCPD. BOC began accepting nominations online on Sept. 25, 2019, at www.bocusa.org/certificantof-the-year. Nominations will be accepted through Jan. 10, 2020.
The statement also outlines ABC’s position on the appropriate use of the telehealth as it relates to the organization’s Code of Professional Ethics, Scopes of Practice, and Facility Accreditation Standards. Visit www. ABCop.org to view the full statement. O&P ALMANAC | NOVEMBER 2019
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HAPPENINGS
O&P ADVOCACY
AOPA Visits Sen. Tammy Duckworth AOPA Executive Director Eve Lee, MBA, CAE, and Director of Government Relations Justin Beland met with Sen. Tammy Duckworth (D-Illinois) in October to thank her for her contributions and support of the limb loss and limb impairment community.
O&P ADVOCACY
AOPA Goes to ISPO Several U.S. O&P stakeholders travelled to Kobe, Hyogo, Japan, last month to take part in the ISPO 17th World Congress, the flagship meeting of the International Society for Prosthetics and Orthotics. Representing AOPA, Executive Director Eve Lee, MBA, CAE, and Director of Strategic Alliances Ashlie White, MA, made the journey to highlight the work AOPA is doing in the area of O&P research. The interactive conference, which was held October 5-8, convenes professionals involved in the care
of persons in need of prosthetic, orthotic, mobility, and assistive devices to learn about scientific and clinical advances, products, new technologies, designs, and materials.
AOPA Attends MedPAC Public Meeting Focused on Competitive Bidding
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NOVEMBER 2019 | O&P ALMANAC
issues. The commissioners examined the potential expansion of DMEPOS competitive bidding and discussed how competitive bidding could potentially be expanded beyond DMEPOS into other areas of the Medicare program. The AOPA representatives offered verbal comments during the public comment section of the session and cautioned the commission on the concept of expanding competitive bidding into noncommodity services such as custom-fitted and customfabricated orthoses and prostheses. They stressed the importance of ensuring that Medicare beneficiaries continue to have access to high-quality clinical care provided by properly certified and licensed practitioners. The AOPA representatives also asked the commission to continue to support an exemption from competitive bidding for orthotists and prosthetists as mentioned in its June 2018 report to Congress.
PHOTOS:AOPA
AOPA staff attended the monthly public meeting of the Medicare Payment Advisory Commission (MedPAC) on Sept. 5, 2019. MedPAC is charged with advising Congress on issues regarding Medicare policy. Justin Beland, AOPA’s director of government affairs, and Joe McTernan, AOPA’s director of coding and reimbursement, education, and programming, took part in the meeting. Participants discussed the Medicare durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) competitive bidding program, specifically the national competitive bidding program for mail-order diabetic test strips. During the conversations, the commissioners began discussing the DMEPOS competitive bidding program in general, including its relative success in achieving significant savings for the Medicare program without significant patient issues. MedPAC staff presented data supporting the premise that competitive bidding did not result in significant patient access
HAPPENINGS
AMPUTEE ATHLETICS
Two New Sports To Debut in 2020 Paralympics More than 4,200 athletes from 160 countries are expected to take part in the 2020 Paralympic Games, to be held August 25 to September 6 in Tokyo, according to Team USA. Some athletes will participate in sports that have not previously been part of the Paralympics. Badminton will makes its Paralympic debut in Tokyo. Participants in badminton will compete in 14 events in Yoyogi National Stadium, the same location where wheelchair rugby will be held. There will be a total of 14 events: seven male events (six singles, one doubles), six female events (five singles, one doubles), and one mixed doubles event. Also new next year will be events centering on the Gyeorugi form of taekwondo, which is geared toward individuals with upper-limb impairments. Participants of four sport classes, K41 to K44, will compete in three weight classes. Matches will take place over three two-minute rounds with one-minute intervals. Athletes will be awarded between two and four points for valid attacks. Information on the upcoming Games, including sport previews and news, will be available on the Team USA microsite at TeamUSA. org/2020Paralympics.
THE LIGHTER SIDE
FAST FACT
About 4.3 million children did not have any health insurance coverage in 2018, an increase of 425,000 (or 0.6 percentage points) from the previous year, largely because of a decline in public coverage. Source: "Health Insurance Coverage in the United States," U.S. Census Bureau, September 2019
O&P ALMANAC | NOVEMBER 2019
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PEOPLE & PLACES PROFESSIONALS
Stella Sieber was honored with the National Institutes of Health (NIH) Champion of Disability Community Award in October. Sieber, who also was a recipient of the AOPA Legislative Advocacy Award in September, was one of several individuals honored during the NIH Office of Equity, Diversity, and Inclusion’s program, Cultivating Inclusion: Honoring NIH Champions and Allies of Disability.
ANNOUNCEMENTS AND TRANSITIONS
Ability Prosthetics and Orthotics’ Jeffrey M. Brandt, CPO, chief executive officer, and Kathleen DeLawrence, chief operating officer, have been honored with a Patriot Award. After First Lieutenant U.S. Army Reserves Cody Smith, CPO, nominated Brandt and DeLawrence for the award, Command Sergeant Major PA Army National Guard (Retired) Jeffery Hall, a volunteer representative for the Employer Support of the Guard and Reserve, visited Ability’s Exton, Pennsylvania, office to present the award. The Patriot Award is presented to individual managers and supervisors who have been nominated by an active military reservist employee for supporting them during their obligations for active duty service. Lisa Guichet has been named the 2019 O&P Woman of the Year, presented by OPGA. In 2016, Guichet co-founded Innovative Prosthetics in the Dallas–Fort Worth area with six employees and has grown the business to three locations and Lisa Guichet more than 30 employees in just under three years. “Lisa’s vision for providing care that addresses a patient’s needs beyond the basics—such as mobile appointment options and a patient advocate program—is helping put a spotlight on this dynamic profession,” said OPGA President Todd Eagen. The O&P Woman of the Year Award was developed by OPGA, a division of VGM Group Inc., and is open to all women who work in the orthotic and prosthetic profession. The 2019 award was presented during the OPGA Member and Supplier Reception as part of AOPA’s National Assembly in San Diego on September 25. This year’s finalists included Tess Buford, CP, a clinician at Fourroux Prosthetics; Kathleen DeLawrence, chief operating officer at Ability Prosthetics and Orthotics; and Esperanza Friedman, CO, president and co-founder at J&J Artificial Limb and Brace. Ajay Nair, BME, MBA, will join WillowWood as vice president of sales, effective Jan. 2, 2020. Nair has 18 years of healthcare, medical device, and pharmaceutical experience, including seven years at Össur developing and expanding Ajay Nair, BME, its Asian markets for orthotics, prosthetics, MBA and orthopedic business units. “My previous experience was formative in helping me understand how to be a better partner to O&P providers as well as the user community,” said Nair, “and helped me grow as a person and leader.” 16
NOVEMBER 2019 | O&P ALMANAC
BUSINESSES ANNOUNCEMENTS AND TRANSITIONS
Ability Prosthetics and Orthotics Inc. has been named one of the Best Places to Work in Pennsylvania for 2019. The award recognizes places of employment that are benefiting Pennsylvania’s economy and workforce. The company also has patientcare offices in Maryland and North Carolina, along with research collaborations that span the country. This is the second year Ability has received this distinction. “Ability is a prosthetic and orthotic company founded under one simple but meaningful principle: enhance the health and well-being of all our patients through artificial limbs and braces that fit their bodies—and their lives,” said Jeff Brandt, CPO, the company’s founder and chief executive officer. “Creating positive outcomes for our patients is central to our patient-centric culture and provides for an environment to attract talented employees and motivates them to go above and beyond for our clients and each other.” Hanger Inc. has been added to the S&P SmallCap 600 Index, effective at the open of trading on Monday, October 28. Specifically, the company (NYSE: HNGR) has been added to the S&P SmallCap 600 GICS (Global Industry Classification Standard) Healthcare Facilities Subindustry index. “We’re proud Hanger will join the S&P SmallCap 600 Index, in addition to our membership in the U.S. SmallCap Russell 2000® Index announced earlier this year,” said Hanger President and Chief Executive Officer Vinit Asar.
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REIMBURSEMENT PAGE
By DEVON BERNARD
Out With the Old Getting ready for a new year means adapting to new rules and requirements
CE
Editor’s Note—Readers of Reimbursement Page are eligible to earn two CE credits. After reading this column, simply scan the QR code or use the link on page 20 to take the Reimbursement Page quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards. CREDITS
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A
S WE HEAD INTO a new decade
and the year 2020, it’s time to think about end-of-year activities and changes for the new year. This month’s Reimbursement Page offers a quick review and tips regarding the new Medicare identification (ID) cards, holiday gift-giving, Medicare participation status, and changes to amounts in controversy.
Use the New MBI Numbers
Health Insurance Claim Numbers (HICNs)—the previous method of identifying Medicare beneficiaries for the purpose of paying claims, verifying eligibility, checking claim status, and other covered functions—have slowly been phased out over the past 21 months and replaced with Medicare Beneficiary Identifiers (MBIs). The transition to MBIs required Medicare to issue new ID cards to all existing and new Medicare beneficiaries, which was scheduled to be completed by April 2019. During the 21-month transition period, providers had the ability to use either a beneficiary’s previous HICN or his or her new MBI when submitting claims, and Medicare would respond with the identifier used by the provider. However, the transition period and the ability to use the HICN ends on Dec. 31, 2019. Beginning Jan. 1, 2020, you may no longer use HICNs; instead, MBIs will be required for all Medicare-covered transactions, with a few exceptions: You may use either the HICN or MBI
for claims appeals and related forms. You also may use either identifier for claim status checks, if the earliest date of service on the claim is before Jan. 1, 2020. If you’re checking the status of a claim with a date of service on or after Jan. 1, 2020, you must use the MBI. It may seem redundant that we are referencing the new Medicare ID cards in this month’s Reimbursement Page since they were discussed in the October 2019 column; however, it is important to emphasize the Jan. 1, 2020, deadline. At the end of September, CGS Administrators reported that only 80 percent of all Medicare fee-for-service providers were using the new MBIs, and DME reported a 74 percent usage rate.
Follow Rules When Giving Gifts Providing gifts to referral sources is acceptable as long as you comply with the rules, which are primarily in place to prevent providers from giving gifts as an inducement to encourage referral sources to provide you with business. First and foremost, gifts of cash or cash equivalents of any type—including gift certificates, gift cards, and free samples—are strictly prohibited. Second, the use of nonmonetary gifts is acceptable if they are of nominal value. Regulations limit the amount of money that may be spent on gifts for referral sources; this gift limit is not a fixed sum and fluctuates from year to year. For 2019, there is an aggregate limit of $416, so any gift or gifts provided to a referral source in 2019 may not
REIMBURSEMENT PAGE
exceed $416. Remember the $416 annual aggregate is a limit, not an entitlement. Next, gifts may not be directly solicited by referral sources. If a referral source requests a specific gift and you provide it, this could be construed as an inducement and a violation of federal antikickback statutes. Finally, the value of a gift may not be tied to the volume of referrals received from a physician’s office. For example, you may not provide a gift of higher value to your regular referral sources than you do to practices that only refer patients periodically. While you are not required to offer the same gift to all of your referral sources, you cannot base your decision on the number of referrals you receive. To learn more about gifts to referral sources, as well as the rules regarding gifts to patients, participate in the Nov. 13, 2019, AOPAversity webinar, “The Holiday Season—How To Provide Compliant Gifts.”
Review Medicare Participation Status
Participation status with Medicare is valid for one year and may only be changed during the open enrollment period, typically mid-November to the end of December. As a quick review, participation status does not relate to whether you wish to be enrolled in the Medicare program; by the act of completing a Medicare enrollment application and obtaining a Medicare supplier number, you are part of the Medicare program. Instead, participation status relates to your agreement with Medicare to automatically accept assignment for all Medicare claims—or to not accept assignment. In short, your decision to be a participating or a nonparticipating provider in the Medicare program hinges primarily on how you wish to handle the assignment of Medicare claims; and the choice to accept assignment only relates to the amount of money you may collect from the patient and
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where Medicare will send its check. When you elect to be a participating provider with Medicare, you agree to accept assignment on all Medicare claims; and by accepting assignment you agree to accept the Medicare allowable for any given item or service as payment in full—you may not balance bill a patient. A nonparticipating provider, on the other hand, is not automatically tied to accepting assignment and has the option to make a claim-by-claim decision on whether to accept assignment. The decision to accept or not accept assignment, however, must be on a claim-by-claim basis; you cannot accept assignment on one claim line and then not accept assignment on another claim line. Also, when a nonparticipating provider elects to not accept assignment, that provider may collect the usual and customary charge from the patient, or balance bill the patient, and is not required to accept Medicare’s allowable as payment in full at the time of service.
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REIMBURSEMENT PAGE
Remember that participation status is tied to tax ID number and not to the location of a facility. So, if you have several locations operating under the same tax ID, it is not appropriate for some locations to be nonparticipating and other locations to be participating; it is all or nothing. If your organization has a current participation agreement in effect for 2019 and you wish to be nonparticipating for 2020, you must submit written notice to the National Supplier Clearinghouse (NSC). The letter does not need to be complex—it may simply be a statement documenting that you no longer wish to be a participating provider—but it must be on your official letterhead and signed by one of your company’s authorized representatives. The authorized representative must be the same person who is on file with NSC as an authorized individual, such as the chief executive officer, chief financial officer, president, or a board member. If you are unsure who is on file as the authorized individual(s) for your company, review Section 15 of your most recent Medicare enrollment application. All participation letters regarding status for 2020 must be received by NSC no later than Dec. 31, 2019. You may not send a letter postmarked by December 31 that arrives at a later date; it must arrive on or by December 31, so factor in mailing time when you send the letter. Consider setting an artificial deadline of a week earlier to allow for mailing time. Letters should be sent to NSC at the following address: National Supplier Clearinghouse P.O. Box 100142 Columbia, SC 29202-3142 If your company is currently enrolled as a nonparticipating provider and you wish to change your company’s status to participating, the process is a little bit more formal. Your company must complete an official Medicare Participation Agreement for 2020 or the CMS 460 form—a one-page form that is easy to fill out. While anyone may fill out the form, it must be signed by an authorized individual. The 20
NOVEMBER 2019 | O&P ALMANAC
completed form also must be received by Dec. 31, 2019—or your participation status will remain nonparticipating. If you do not wish to make any changes to your participation status for 2020, simply do nothing and your status will remain the same.
Know the New QIC and Revised AICs
Medicare recently made changes to the contractor handling reconsideration requests at the second level of appeals and to the amounts in controversy (AIC) for the third (administrative law judge, or ALJ) and fifth (judicial review) level of appeals. On May 28, 2019, Maximus Federal Services Inc. was awarded the contract to serve as the Qualified Independent Contractor (QIC) to administer all reconsiderations on processed claims for durable medical equipment, prosthetics, orthotics, and supplies; Maximus currently holds multiple contracts, including serving as the QIC for Part A and Part B Medicare. This new contract includes any new appeals received on and after Sept. 1, 2019, and telephone discussions and reopening activities under the Telephone Discussion and Reopening Process Demonstration project. Any appeals prior to Sept. 1, 2019, will be handled by the previous contractor, C2C Solutions. On Oct. 7, 2019, Medicare released the new AICs, or the amount of money that must be in dispute in order to file an appropriate appeal. The 2020 AIC for ALJ hearings, or the third level of
appeal, is $170. This AIC, if not met by a single claim, can be combined with multiple claims. This amount represents an increase of $10 over 2019. The AIC threshold amount for a judicial review, the fifth and final level of appeal, changes to $1,672.34. However, this amount is rounded to the nearest multiple of $10, resulting in the new AIC of $1,670; this was an increase of $40 over the current 2019 AIC amount. Just as with the ALJ level, you may combine multiple claims to meet the AIC threshold if needed.
Busy Time of Year
There’s a lot to do as we close out 2019. Remember to use MBIs going forward, and to comply with all rules if you decide to go gift shopping this holiday season. And be sure you’re satisfied with your participation status for 2020, and familiar with the rules regarding the QIC contractor and revised AICs. Devon Bernard is AOPA’s assistant director of coding and reimbursement services, education, and programming. Reach him at dbernard@AOPAnet.org. Take advantage of the opportunity to earn two CE credits today! Take the quiz by scanning the QR code or visit bit.ly/OPalmanacQuiz. Earn CE credits accepted by certifying boards:
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This Just In
Modernizing the Ethics Rules CMS proposes significant changes to the Stark physician self-referral and federal antikickback regulations
O
N OCT. 17, 2019, CMS issued a
proposed rule that would significantly alter the Stark physician self-referral regulations and the federal antikickback regulations. The proposed rule represents the first significant changes to the regulations since the laws were enacted in 1989. According to CMS, the proposed rule will address undue regulatory impact and burden of the physician self-referral law that has been rendered obsolete through the use of emerging technology and the shift from a volume-based healthcare delivery model to a value-based healthcare delivery model. The proposed rule was issued as part of CMS’s Patients Over Paperwork Initiative and the U.S. Department of Health and Human Services’ Sprint to Coordinated Care. Both programs seek to ease unnecessary regulatory burden on healthcare providers in the interest of facilitating the delivery of efficient, high-quality healthcare. CMS will receive public comments on the proposed rule until 5 p.m. EST on Dec. 31, 2019.
Current Regulations
The Stark physician self-referral and federal antikickback regulations often are used interchangeably, but they are very different. 22
NOVEMBER 2019 | O&P ALMANAC
The Stark regulations prohibit a physician from making referrals for designated health services payable by Medicare to an entity in which the physician, or an immediate family member, has a financial relationship. In addition, Stark regulations prohibit the entity to which the referral was made from billing Medicare for services provided as a result of the prohibited referral. Federal antikickback regulations prohibit the exchange of remuneration, defined broadly as anything of value, for referrals for services that are payable by a federal program such as Medicare. While the regulations are sometimes discussed together, they are very different in their specific prohibitions.
Potential Changes
The proposed rule attempts to modernize both the Stark and federal antikickback regulations to help to facilitate the transition to a value-based healthcare delivery system that relies on well-coordinated care to achieve positive outcomes. CMS indicates that the original Stark physician selfreferral and antikickback regulations were relevant in a traditional fee-forservice, volume-based healthcare market but must be updated to allow for certain arrangements that allow for and promote the coordination of care among various healthcare providers.
This Just In
Significant proposed changes to the Stark physician self-referral and federal antikickback regulations include the following: • Exception from Stark physician self-referral regulations for “valuebased arrangements” designed by or entered into by physicians and other healthcare providers for the purpose of delivering efficient, well-coordinated care • New guidance and clarification of specific requirements that must be met in order to remain compliant with Stark physician self-referral and federal antikickback regulations • New exceptions for nonabusive, beneficial relationships between physicians and other healthcare providers—for example, the proposed rule would allow for the donation of cybersecurity resources that were provided in the interest of safeguarding patient information being shared by multiple providers on the coordinated healthcare team.
While the stated intent of the proposed rule is to reduce undue regulatory burden on providers who are delivering healthcare in an ever-increasing value-based system, CMS is cognizant that the original intent of the Stark physician self-referral and antikickback regulations was to prevent fraud and abuse within the Medicare system. The proposed rule is very clear that none of the exceptions that are being proposed should expose the Medicare program to inappropriate remuneration to unscrupulous providers. On the contrary, CMS indicates that any proposed exception, while intended to reduce unnecessary regulatory burden on providers, is not intended to allow for abuse of the Medicare system.
What Happens Next?
AOPA has completed a preliminary review of the proposed rule and will be developing comments for submission to CMS. While the proposed rule only
addresses prosthetics and orthotics within the larger context of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), the proposed rule asks for public comment as to whether value-based exceptions are appropriate for arrangements involving DMEPOS suppliers and laboratories. AOPA will review the relevant provisions of the proposed rule that establish this question and provide appropriate comments to CMS. While the proposed rule represents the first major changes to the Stark physician self-referral and federal antikickback regulations since their initial introduction, the proposed exceptions are very specific to allowing proper coordination of healthcare services without inadvertently falling out of compliance with the intent of the regulations. AOPA supports CMS’s efforts to ease unnecessary regulation on all healthcare providers if they do not expose the Medicare program to fraud and abuse by unscrupulous providers.
O&P ALMANAC | NOVEMBER 2019
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COVER STORY
One Step Ahead of Veterans’ Needs M. JASON HIGHSMITH, PHD, PT, DPT, CP, FAAOP, DISCUSSES VA’S MULTIDISCIPLINARY APPROACH TO CARE, RESEARCH PRIORITIES, AND PARTNERSHIPS WITH PRIVATE O&P PRACTICES
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COVER STORY
M. Jason Highsmith, PhD, PT, DPT, CP, FAAOP, began his tenure as the national director of orthotic and prosthetic clinical services at the U.S. Department of Veterans Affairs (VA) one year ago, after serving for four years as deputy chief of the Research and Surveillance Division of the DoD/VA Extremity Trauma and Amputation Center of Excellence. Highsmith recently spoke with O&P Almanac about O&P services within the VA, adoption of technologies and research initiatives, partnerships with outside organizations and community practices, and expected changes regarding electronic health records.
O&P ALMANAC: What does your job
entail as national director of orthotic and prosthetic clinical services? M. JASON HIGHSMITH, PhD, PT, DPT, CP, FAAOP: The National Program
Office and the national director of O&P services are responsible for housing and drafting policies that directly impact the practice of clinical orthotics and prosthetics within VA. VA’s National Clinical Orthotic & Prosthetic Services Office is a part of Rehabilitation & Prosthetics Services (RPS), which also contains many of the other allied rehabilitation disciplines. For example, physical therapy, occupational therapy, orthotics and prosthetics, Prosthetic and Sensory Aid Services (PSAS), and others are all a part of the RPS office. We’re responsible for drafting and curating the policies for clinical O&P. There are policies on accreditation, coding, general O&P practice, therapeutic footwear, etc. We also oversee
the O&P residency program, and we’re responsible for interfacing with other offices within VA, other government agencies like [the U.S. Department of Defense and the National Institutes of Health], Congress and its members, and professional trade organizations. We also participate in site visit work, where we can do quality assurance at a site to make sure policies are in place and being adhered to. We have a role in partnering with other offices to draft practice guidelines. We have two Clinical Practice Guidelines (CPGs)—one for upper-limb amputee care and one for lower-limb amputee care—and we have a Business Practice Guideline. We also have numerous Clinical Practice Recommendations that we produce as well; one example is a recommendation on advanced carbon-energy-storing ankle-foot orthoses (AFOs). It really is all about administering the benefits, services, components, devices, and programs that veterans need. O&P ALMANAC | NOVEMBER 2019
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COVER STORY
M. Jason Highsmith, PhD, PT, DPT, CP, FAAOP, works with a veteran patient. O&P ALMANAC: What are areas of
priority with regard to ensuring optimal O&P interventions for veterans? HIGHSMITH: The priority is to assure
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available device, VA O&P partnered with the Amputation System of Care Team and others to make sure VA clinicians had guiding documents available as practice resources. The collaborative team produced a Clinical Practice Recommendation for the utilization and implementation of the Luke Arm as it became commercially available. Earlier I mentioned advanced carbon-energy-storing AFOs. Years ago, when the wars in Iraq and Afghanistan began to wind down, including large withdrawals of troops, large numbers of service members began separating from active duty to veteran status. This increased enrollment into the VA system and increased the patient volume in many VA clinics. Our colleagues that studied the
PHOTOS: U.S. Department of Veterans Affairs
that our veterans have access to the most effective, evidence-based O&P interventions, to be delivered in facilities by a skilled and qualified O&P professional workforce. To accomplish that, we’re in a constant state of reviewing and updating VA practice and policies to make sure that VA practice and policies stay current with changes happening in accreditation, practice, science, and education. This ensures that VA’s workforce is ready and prepared to deliver the services—either within a VA facility or in collaboration with an O&P partner in the community.
For example, we just updated our accreditation guideline, and partnered with the American Board for Certification in Orthotics, Prosthetics, & Pedorthics and the Board of Certification/Accreditation to make sure that VA is current with what the accrediting bodies have in their stated practices. In addition, VA’s Business Practice Guideline was just revised and updated to reflect changes in VA’s clinic identification and documentation processes. In terms of CPGs, we have two, and just published a revision on the lower-limb one, to make sure that the latest science was captured. An example of program office involvement related to components may include the Luke Arm. As the Luke Arm was translating from an experimental to a commercially
COVER STORY
epidemiology of limb trauma observed large numbers of service members and veterans were in need of advanced carbon-energy-storing AFOs. Clinical O&P partnered with the dual VA & DoD Extremity Trauma & Amputation Center of Excellence to draft a Clinical Practice Recommendation and training program for VA’s orthotists to assure that VA was equipped and ready to deliver those services across the network. O&P ALMANAC: Why is it important
that orthotists and prosthetists be aware of the aging veteran population and their health needs?
HIGHSMITH: Many active-duty military
members are career service members and may serve up to retirement age. Alternatively, their aspirations may have been to serve until retirement, but that plan was interrupted due to injury that may have occurred [between age of enlistment/commissioning up through retirement age]. Because of that, VA is likely to receive veterans of diverse ages when they are separating from active military service and transitioning to receiving veteran benefits, which they are likely to need for the rest of their lives. If they do choose VA benefits, then the system has to be able to provide appropriate care for them, regardless if they’re recently separated 20-somethings or of retirement age. VA could receive them at any time along that walk of life. Consider World War II Veterans. Today in 2019, these veterans in many
cases are in their 90s. Because of their advanced age as a group, their needs today are quite different than when they first came back from combat. Similarly, many of the Vietnam veterans may be approaching or into their 70s today. VA will likely and proudly be providing care for them into their advanced years. There are veterans from the more recent conflicts as well—Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn—right now VA has them in their younger years, but they too will continue aging, and VA will follow and care for them as well into their advanced years. It’s for those reasons that VA has to be prepared to deliver care to an aging and age diverse population. O&P ALMANAC: What are some of
the new technologies that are being used and are making a difference in veteran O&P patient care? HIGHSMITH: There are a number
of newer O&P technologies that are being utilized in large supply by veterans, such as microprocessor knees, microprocessor foot-and-ankle systems, microprocessor upper-limb components like the Luke Arm, the TASKA hand, i-limbs, etc. These are all being used and prescribed around the network [for] veterans. Every one of these technologically advanced components is clinically important for the individual prescribed to receive it—particularly because in VA,
the veteran is included in the decision-making process. One of the things that sets the VA network apart from other systems is the fact that VA has an amputation “system of care,” so when a patient that needs O&P services comes into VA, they’re coming in to a multidisciplinary clinic. There’s a prescribing physician that’s knowledgeable about amputee and prosthetic care, among other things like pain management and mental health, and [that physician is] very tuned in to the unique needs of veterans. There’s also case management, some procurement specialization, mental health professionals, physical therapists, occupational therapists—all in addition to O&P. The technologies are important and have a key role, but the more advantageous thing is the multidisciplinary approach, the use of outcome measures, and adherence to CPGs and best practices. These are the things that really make a difference in a veteran’s rehab and reintegration back into society. O&P ALMANAC: Can you share any
recent changes or new programs that may have an impact on veteran consumers of O&P services, or that may impact O&P providers? HIGHSMITH: The Secretary of the VA
has a focus on modernization. There’s work on a new electronic health records system (EHR), and when it rolls out, beginning in 2020, it will be potentially practice changing. It’s a new way of documenting, allowing more visibility of the team decision making. It will allow a more uniform, universal use of outcome measures that we really haven’t had in the past. So while VA currently has systems in place to look at populations and subpopulations of veteran groups, including amputee patients and limb-traumatized patients, VA not only will be able to look at them as groups epidemiologically, but will also be able to look at the team decision making, the outcome measures, and the goals. O&P ALMANAC | NOVEMBER 2019
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COVER STORY
Beyond that, there’s the day-to-day and annual business of constantly being on the lookout for changes that impact our own policies, and one example we’ve talked about is accreditation. Making sure, for example, that as things change with accreditation and credentialing, the VA is staying current with those standards as well. VA is proud of its CPGs and seeks to ensure they remain current. VA recently published the revision to the lower-limb, and will probably start looking at revisions to the upperlimb—to ensure that as new science is published, that it’s being captured and disseminated to VA clinicians. O&P ALMANAC: What can you share
about the benefits of partnerships the VA is forging with academic and other institutions? HIGHSMITH: In the area of partner-
ships, our office attempts to collaborate with other VA offices and with groups outside VA. One example is that I do some service work with our VA Office of Research and Development, particularly in the prosthetic engineering research portfolio. This affords insight into the areas of innovation, development, and new devices. Both offices benefit.
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NOVEMBER 2019 | O&P ALMANAC
The O&P Clinical Services office does have numerous partnerships with academic institutions, not only for research, but also for O&P residency education. There’s some nuance to that—because this is VA, VA O&P residents receive great experience because of our veteran patient population. Conversely, VA is certainly not a pediatric hospital, for instance. Orthotic residents need time to consider pediatric diagnoses and management, so VA is looking at partnerships through the residency program to make sure that residents have some time to be able to go to a partnering facility and experience orthotic cases. Those partnerships are happening out in the community, with different practices that do manage those types of cases, and these are vital to the VA residency program. Again, this is merely one example of partnerships in the spirit of education. O&P ALMANAC: What can you share
about the Extremity Trauma and Amputation Center of Excellence (EACE), where you spent four years before taking on your current position—what sorts of research and studies are being done there that will lead to advances in orthotics and prosthetics?
HIGHSMITH: When I was hired onto
VA full time, I was hired on as deputy chief of research for EACE. I have not been in that role in over a year, but I do work very closely with B.J. Randolph, PhD, PT, who is the VA lead for EACE. One of the things that EACE was trying to do, because it is a Congressionally Mandated Dual Agency Center—meaning it has staff in both DoD and VA, was to make sure the studies were collaborative, to the extent it made sense and was feasible. We would try to have multisite, multisector-research projects. One study that I’m leading still, that started during my time at EACE, is the IM ABLE study—or Injuries Managed With Advanced Bracing of the Lower Extremity. We started off looking at the epidemiology at how many service members had suffered limb trauma through OEF, IEF, and New Dawn. The numbers are very high—they’re on the order of an estimated 30,000 service members that suffered limb trauma. Knowing that, and knowing that many of those individuals would likely transition to VA care, Dr. Randolph had the foresight to say, ‘We need to ramp up some training efforts to make sure that we have the infrastructure and the clinical expertise in place to provide interventions that these folks have become accustomed to through the military infrastructure, here at the VA.’ So we organized training at a number of VA’s flagship O&P facilities, pulled some of the leading orthotists from around the network together, provided training on advanced carbon-energy-storing AFOs, put out a Clinical Practice Recommendation, organized regular calls, and applied for a clinical trial grant—which became the IM ABLE study. All of that background work was done to make sure VA can provide those services that were really needed as a result of the wars in Iraq and Afghanistan, and then build the infrastructure and clinical expertise, and put a clinical trial in place. The clinical trial has about a year to go and has enrolled about 30 [out of a goal of 120] patients at this point.
COVER STORY
EACE does a great job of bridging the two agencies in terms of research— impactful, clinically translational research that has the potential to affect the way veterans receive care and really affect what we know about how veterans receive care. O&P ALMANAC: Are there any other
recent studies/research that pertain to O&P and that would be useful for our readers to learn about? HIGHSMITH: We’ve organized a state-
of-the-science conference around transfemoral interfaces. We’ve had the conference [planning] meeting, and we have the draft manuscripts. We’re organizing a Delphi process with a large community partner, to look at ways transfemoral interventions are provided in both the private sector and VA—and then bring those results together to develop postulates and possibly create a Clinical Practice Guideline or Recommendation on transfemoral interface science. I also want to mention a very exciting program at the Puget Sound/ Seattle VA. Bruce Sangeorzan, MD, Glenn Klute, PhD, and Joseph Czerniecki, MD, are opening a new research center called the Center for Limb Loss and MoBility (CLiMB) Center, and I was honored to be invited to be a keynote speaker at the building opening celebration in a couple of weeks. There’s so much they’re doing in research there—they’re working in the areas of prosthetic engineering,
componentry development, clinical trials, limb loss prevention, and also big data-type analyses. Great team doing lots of cutting-edge work! O&P ALMANAC: For those O&P
providers in the private sector who contract with the VA to provide O&P services to veterans, what would you like to share about how the VA and private providers can work together to offer optimal care? HIGHSMITH: If you’re a private prac-
tice that is not already engaged in business with the VA and are interested in doing so, probably one of the most helpful things you could do is find the AOPA webinar on the topic and start with that. That will give you the high-level overview of doing business with the government, the contracting process—the basics. During the September AOPA National Assembly, we did a session on “How To Do Business With the VA,” and discussed the layout of VA O&P, how PSAS works with clinical O&P, and so forth. Understanding that is very helpful to start down the road of partnering with the VA.
VA is interested in making sure that veterans have access to high-quality O&P care—efficient, evidence-based, impactful care that meets their goals and helps patients reintegrate. That being the case, VA is very proud to partner with community providers of O&P care. VA needs to do that; VA has an O&P staff on the order of about 400, and if you think about it, 400 across 50 states, geographically dispersed—there’s a lot of veterans that need care out there. So VA has to partner with the community. With the goal of providing world-class, efficient, impactful O&P care, you have to have a partnership to provide care to veterans. We are proud of the internal services that we provide, and we have a lot of veterans that want to come to a VA facility to receive their care—it’s multidisciplinary, and that sets VA apart from a lot of different practices out there. But in order to meet the demand, VA has to have those partnerships with private O&P practices. Editor’s Note: Visit AOPAversity on the AOPA website to view the September 2019 AOPA webinar titled, “VA Updates: Contracting, Special Reports, and Other News.” O&P ALMANAC | NOVEMBER 2019
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By CHRISTINE UMBRELL
Damage Control Strategies for preventing diabetic foot ulcers and avoiding recurrences—and profiting from these services
NEED TO KNOW • Up to 10 percent of the 30.3 million individuals living in the United States who have diabetes will develop a foot ulcer. While many ulcers heal, others become infected— and some of those become so problematic as to require amputation. • Pedorthists, orthotists, and prosthetists become part of the solution by providing diabetic shoes, socks, and orthoses that promote foot health and prevent ulcers from developing or recurring. • New technologies are coming to market that may make it easier for patients and their clinicians to monitor their feet and ensure timely and appropriate interventions when complications arise; some of these innovations include intelligent socks, smart insoles, temperaturemeasuring bath mats, and removable smart boots. 30
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• While keeping pace with new technologies is critical, it’s also important for today’s clinicians to ensure their patients are taking advantage of the traditional tools for ulcer prevention and treatment in the form of proper footwear, diabetic socks, and inserts. • O&P facilities that do not currently offer diabetic shoes may realize several benefits from adding these services, including loyal customers and an increase in referrals for ankle-foot orthoses and other devices. • O&P and pedorthic professionals can be even more effective at improving the foot health of diabetic patients if they coordinate their efforts to optimize diabetic patient care and participate in multidisciplinary healthcare teams.
E
VERY 1.2 SECONDS, SOMEONE in
the world gets a diabetic foot ulcer. “About half the time, that ulcer gets infected,” says David G. Armstrong, PhD, DPM, a podiatric surgeon who has spent his career focusing on improving foot health. “Every 20 seconds, someone with diabetes gets an amputation.” Moreover, in the United States— where more than 30 million people have diabetes—patients with diabetic foot ulcers are twice as costly to Medicare as those with diabetes alone, and the cost of diabetic foot ulcers is greater than that of the five most costly forms of cancer, according to Armstrong, a professor of surgery and director of the Southwestern Academic Limb Salvage Alliance (SALSA) at the Keck School of Medicine at the University of Southern California (USC). Given the magnitude of the problem, healthcare professionals who focus on the foot are faced with
the monumental task of helping to reduce amputations. It all starts with promoting foot health. Once a diabetic patient develops his or her first ulcer, that patient is never really cured. “Forty percent of patients who get one ulcer will get another ulcer within a year,” Armstrong says. “Two thirds will get another ulcer within three years, and three quarters of patients” will have a recurrence within five years— meaning patients whose first ulcers heal are not “cured,” but “in remission.” The good news is that many of these wounds and infections can be prevented, and remission can be prolonged, Armstrong says. Pedorthists, orthotists, and prosthetists all have critical roles to play in treating this important patient population.
New Technologies
Advanced technologies have come to market that may make it easier to prevent and treat ulcers, and may help patients salvage their gait, according to Armstrong. While not all of these products are covered by insurance—yet—it’s important for O&P professionals to be aware of what is available and how these tools may promote foot health.
David G. Armstrong, PhD, DPM PHOTOS: David G. Armstrong, PhD, DPM, Keck School of Medicine, USC
For example, intelligent socks, such as those manufactured by Sensoria Health, are designed to monitor patient activity and pressure, and will soon be able to monitor temperature, according to Davide Vigano, cofounder and chief executive officer of Sensoria. In addition, “smart insoles” have been introduced that can identify hot spots on people’s feet by monitoring temperature and communicating to the patient or healthcare professional when an area is heating up, says Armstrong. “They look ordinary, and they are not costly. Being that wounds
David G. Armstrong, PhD, DPM, (left), collaborates with team members. heat up before they break down, they can signal inflammation and help prevent amputation,” he says. Evaluating skin temperature can help a patient seek treatment before a wound becomes a problem, according to Armstrong. Smart bath mats are another helpful innovation. Patients can be directed to step on a next-generation bath mat each day to have their foot temperature measured. The bath mat then “communicates” via a text, phone call, or the mat itself, when a toe has gotten hotter. This information prompts the patient with diabetes to visit a clinician before a wound fully develops. Armstrong says his team been working on wearables for diabetes care for 25 years. Often paired with smartphones and mobile apps, “wearables are ubiquitous now and provide astonishing data,” he says. Smartphones can collect activity data and monitor other vital signs and indicators. “There are algorithms that can nudge patients to move so they don’t get pressure sores,” he explains.
Armstrong (left) works with Giacomo Clerici, MD, in completing a surgery in Bergamo, Italy.
O&P ALMANAC | NOVEMBER 2019
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Armstrong completes a foot exam and puts dressing on a wound.
Diabetic Shoes and Inserts
While keeping pace with new technologies is critical, it’s also important for today’s clinicians to ensure their patients are taking advantage of the traditional tools for ulcer prevention and treatment in the form of proper footwear. Unfortunately, fewer than 20 percent of eligible beneficiaries use the Medicare benefit provided in the Therapeutic Shoe Bill to receive therapeutic shoes and inserts, says Erick 32
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Janisse, CO, CPed, corporate trainer at Dr. Comfort. The large number of diabetic patients who do not wear appropriate footwear is a big problem, according to Janisse, because diabetic shoes are “incredibly valuable” in preventing ulcers and amputations. A study conducted at the U.S. Department of Veterans Affairs in Seattle a few years ago found that 30 percent of amputations started as improperly fitting footwear, which led to ulcers and amputations, says Janisse.
Erick Janisse, CO, CPed
While much of the problem lies in beneficiaries choosing not to seek healthcare—or not understanding that they need care, according to Janisse, he notes that more healthcare professionals should be monitoring patients and providing the services required by diabetic patients. “In O&P, a lot of businesses are getting away from providing diabetic shoes—and that’s a huge problem” since so many patients require access to these products and services, he says. While some business owners and managers may feel the profits are not high enough to warrant providing diabetic shoes, Janisse points out that, as long as facilities treat enough patients—and are mindful
PHOTO: David G. Armstrong, PhD, DPM, Keck School of Medicine, USC
One of the newest innovations in the diabetic foot space is a remote patient monitoring system that allows for patient monitoring via smart sensors, called the Motus Smart and manufactured by Sensoria Health and Optima Molliter. The removable “smart boot” is embedded with sensors and equipped with different density interchangeable insoles to take pressure off the area of ulceration and improve blood circulation. The sensors work with a dedicated real-time mobile app, artificial intelligence algorithms that detect patient behavior, an alert system, and a web dashboard to inform caregivers and clinicians of noncompliant behaviors, according to Vigano. It is currently being trialed at Pisa Hospital, with the expectation that more patients will be fit with the smart boot soon. As technologies such as these come to market and become available for widespread adoption, Armstrong hopes clinicians will help inform patients of their availability—and that more patients will seek treatments that prevent amputations and promote mobility.
of the number of patient visits associated with providing shoes—it can be a profitable segment of an O&P practice. “The documentation requirements are not that cumbersome” when compared to the documentation required for prostheses, Janisse says. “Medicare is pretty clear, and the documentation requirements are spelled out—they even tell you how to write your notes,” he adds, meaning that documentation becomes less burdensome if a facility starts to do a large volume and becomes efficient. “And reimbursement for diabetic shoes and orthoses has actually increased every year.” Janisse suggests that more O&P facilities consider ramping up services for this underserved population, and offers four suggestions on how it can be a profitable undertaking. First, he says that his own “cost analysis” has shown that it’s important to fit and deliver shoes over the course of two patient visits, or three at the most. This means ordering right-size shoes the first time. “Using a manufacturer-specific Brannock Device is critical,” he says, explaining that the sizing of shoes may differ at each shoe company, so fitters should use the Brannock Device designed for the brand of shoe they will be ordering. And while providers may need to purchase Brannocks for each brand, some manufacturers will provide sizing devices for free, according to Janisse. Second, he suggests stocking shoes for patients to try on to confirm a correct fit before an order is placed. “Try to keep a small inventory of core sizes for men and women,” he says. Some manufacturers may be willing to loan trial shoes for free or at a significant discount. Third, Janisse advises diligence when completing and submitting paperwork. “Don’t bill yet if you’re not 100 percent confident that you have all of the correct documentation,” he says. “Don’t let a patient walk out the door until you have all of the paperwork in place. Remember you have a year to bill.”
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Measurement Tools for Diabetic Inserts
W
HILE THE VALUE OF intervention in the form of foot
Fogg found that different materials have different abilities to offload. The results for individuals using standard U.S. diabetic inserts made of foam didn’t look much different than the results for those individuals without any inserts at all. But the results for individuals using a German-made insert (made from a dual material, Nora® Lunatec combi motion composite sheets) were much more significant, and indicated the advanced material offloads more pressure. He concluded that better materials are needed to offload the diabetic foot in the United States. He does not believe the current foam material that is covered by Medicare and specified in the Therapeutic Shoe Bill is the optimal choice of material. He suggests advocating for a change to the bill that would allow for one-pair-per-year of diabetic insoles made of better material, rather than the current three-pairs-peryear made of lower-quality foam material. “If you really want to prevent ulceration on a high-risk patient, you could use a single pair of foot Patient without orthosis (left) orthoses made of a better and with an orthosis made of material,” he says. more responsive materials (right) “Part of the problem is that we put insoles in shoes, and we hope they work, but we don’t know” if they work, Fogg says. “The re-ulceration rate is well over 50 percent— so that means something’s not working.”
orthoses and diabetic shoes for preventing ulcers is clear, measuring and quantifying the efficacy of individual inserts remains a challenge. “Not a great deal of work has been done on how a shoe or insert would benefit a diabetic patient,” says Jonathan Fogg, CPed, CFo, market development manager, SureStep. “If the outcome you’re desiring is to use a shoe [with inserts] to offload pressure, you need to be able to measure that.” Fogg decided to investigate methodologies for measuring Jonathan Fogg, how well orthotic CPed, CFo inserts are achieving their goals. He worked with a colleague from Park City Pedorthic to access a foot analysis system used for fitting ski boots. The system features a pressure-measuring plate with thousands of sensors that show how the foot behaves throughout the entire movement phase. In Fogg’s trial, he evaluated diabetic patients using the pressure-measuring plate. “We put the foot orthosis into the sock instead of the shoe so we could analyze the feet without the shoe being involved,” he explains.
Patient without orthosis (left) and with a standard over-the-counter diabetic foot orthosis (right)
NOVEMBER 2019 | O&P ALMANAC
IMAGES: Jonathan Fogg, CPed, CFo
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Fourth, he recommends employing certified fitters to do most of the diabetic shoe work. “Fitters are valuable employees to have, and the process for becoming a certified fitter is not onerous,” Janisse says. Some facilities may want to train noncertified staff members to become certified fitters. O&P facilities that offer diabetic shoes and other foot management products and services stand to benefit not just from knowing that they are providing much-needed services, but also from earning loyal customers and word-of-mouth referrals. Many referral sources prefer to work with facilities that offer the full range of orthotic, prosthetic, and pedorthic services, according to Janisse. “Doctors don’t like it when they send you patients and then find out you don’t do shoes,” he says. Offering diabetic shoes “helps with referrals for ankle-foot orthoses and other devices.” Of course, pedorthists and orthotists should remember that not all diabetic shoe patients are Medicare patients, and marketing to non-Medicare patients could drive profits at O&P facilities. “We tend to get drawn in to the Medicare diabetic patients, but there are millions of non-Medicare patients who need to reduce the pressure in their foot via foot orthoses,” says Jonathan Fogg, CPed, CFo. For example, he notes there are many 50-year-old individuals with diabetes who could benefit from orthotic intervention and therapeutic shoes, and who may have employer-sponsored insurance.
Appropriate Socks
PHOTO: AOPA
Many patients who have diabetes should be wearing depth-inlay shoes, multidurometer inserts, and highquality diabetic socks—and pedorthists and orthotists can help their patients accomplish this goal, says Doyle Collier, CP, director of technical education at Knit-Rite. Specially designed socks may be particularly helpful for patients who already have one amputation. “We always inspect the sound side limb” when treating patients to
help ensure their natural foot remains ulcer-free, says Collier. Of all the modalities used in the conservative management of the diabetic foot, hosiery is most often overlooked by practitioners, according to Janisse. Collier recommends that patients at risk of developing foot ulcers wear high-quality diabetic socks that remove moisture, are wrinkle-free and seam-free, and do not restrict circulation. “We have socks made of X-static fibers that are antimicrobial and antifungal to help prevent odors, wick moisture, and keep the body drier,” he says. Ensuring patients wear appropriate socks and inspect their feet every day can help patients catch ulcers at the early stage, so they don’t turn into something more serious, says Collier.
Collaborative Care
Orthotists, pedorthists, and clinicians play an important role in working with diabetic patients. By investigating how newer technologies may help their patients and educating patients regarding coverage of appropriate footwear and inserts, clinicians can be sure they are best meeting patients’ needs. Healthcare professionals can be even more effective at improving the foot health of diabetic patients if
Doyle Collier, CP
they coordinate their efforts to optimize diabetic patient care, suggests Armstrong. “Even more important than technology is having a pedorthist/ orthotist/prosthetist in our clinic with us,” says Armstrong, who takes a multidisciplinary approach in his work at Keck Medicine and SALSA. “The orthotist or pedorthist works actively as a member of the team—and is often the most important member of the team.” Pedorthic and orthotic intervention can keep patients moving, extend ulcer-free days, and lead to less severe ulcers, Armstrong says. A collaborative approach to care will be key as baby boomers age and diabetes complications continue to drive up healthcare costs. “We need to get out in front of this issue, and not get mired in the documentation,” says Armstrong. “If we can bring our heads together, we can change the game.” Christine Umbrell is a contributing writer and editorial/production associate for O&P Almanac. Reach her at cumbrell@contentcommunicators.com. O&P ALMANAC | NOVEMBER 2019
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PRINCIPAL INVESTIGATOR
Upper-Limb AI Patrick Pilarski, PhD, applies his expertise in machine learning to advance O&P technologies
P
Rehabilitation, Pilarski focuses his work on advanced computing technologies. In that capacity, he pursues “new methods that will allow artificial limbs to improve, adapt, and change their behavior in response to the needs and day-to-day changes experienced by their users,” Pilarski explains. He works with collaborators and students in pursuing techniques for reducing the time or effort needed for someone to control a robotic arm—called “adaptive switching.” He also seeks ways to improve how a prosthesis relays information back to its user and how “a nontechnical caregiver or a person with amputation can train a myoelectric prosthesis to better perform fluid, natural movements.” As artificial intelligence becomes more advanced, Pilarski has found O&P to be “one of the most immediate and most beneficial places to study how we can extend and amplify human potential.” He studies machine intelligence and machine learning in assistive technologies, focusing on “restoring—and perhaps even someday exceeding— capabilities someone has lost through injury, illness, or At his lab at the University of Alberta, Patrick M. Pilarski, PhD, studies new methods other adverse life events.” for controlling a robotic arm. O&P Almanac introduces individuals who have undertaken O&P-focused research projects. Here, you will get to know colleagues and healthcare professionals who have carried out studies and gathered quantitative and/ or qualitative data related to orthotics and prosthetics, and find out what it takes to become an O&P researcher.
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have earned his doctorate degree in electrical and computer engineering, but he has chosen to apply his extensive knowledge to the field of O&P. Currently on faculty at the University of Alberta as a Canada Research Chair in machine intelligence for rehabilitation and an associate professor in the Division of Physical Medicine and
PHOTOS: Patrick Pilarski, PhD
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ATRICK M. PILARSKI, PhD, may
PRINCIPAL INVESTIGATOR
Pilarski and his team study machine intelligence and machine learning in assistive technologies.
Interdisciplinary Approach
PHOTOS: Patrick Pilarski, PhD
In researching upper-limb strategies, Pilarski works on a team with faculty members, prosthetists, orthotists, occupational therapists, and other care providers to study the way advanced computing technologies and robotic devices can improve life for people with hand and arm amputations. “Our team at the university develops and shares a range of open-source technologies to support upper-limb prosthesis research,” he says. His team was involved in creating the 3D-printed Bento Arm and HandiHand devices, which are now in use for research in clinics and universities in North America, Europe, Australia, and additional locations. Pilarski and his collaborators have developed methodologies for measuring the impact that new technologies for prosthetic control and feedback have for people who use robotic prostheses as part of their daily life, via the creation of a prosthetic gaze and movement analysis suite (GaMA) in an outcome-metrics initiative—a project led by Jacqueline Hebert, MD, FRCPC. The goal is to provide practitioners with “easy-to-use measures for the evaluation of new upper-limb prosthetic control and feedback technologies,” he says. In addition to these projects, Pilarski also leads the Alberta Machine Intelligence Institute Adaptive Prosthetics Program—an interdisciplinary initiative focused on creating intelligent artificial limbs to restore and extend abilities for people with amputations. As part of this research, Pilarski explores new machine learning techniques for sensorimotor control and prediction, including methods for human-device interaction and communication, long-term control
adaptation, and patient-specific device optimization. He also has pioneered techniques for rapid cancer and pathogen screening through work on biomedical pattern recognition, robotic micromanipulation of medical samples, and hand-held diagnostic devices. In all of his projects, Pilarski strives to keep the limb loss population at the forefront of his activities. “The work by our team has a large intended impact for users of upper-limb powered hand and arm prostheses, in that we aim to enable natural control and intuitive feedback from prosthetic limbs,” he says. “We seek to make prostheses feel and respond more like a biological limb or easy-to-use functional extension of the body.” But the work is not limited to prosthesis users, as the core technology and evaluation measures his team
employs could theoretically impact users of upper- and lower-limb exoskeletons, powered orthoses, and other assistive rehabilitation technologies.
Prepared for Advancement
Pilarski’s central research interests— reinforcement learning, real-time machine learning, human-machine interaction, rehabilitation technology, and assistive robotics—emerged as he completed his undergraduate and postgraduate studies. He received a bachelor’s degree in electrical engineering from the University of British Columbia in 2004, followed by a PhD in electrical and computer engineering from the University of Alberta in 2009. He completed his postdoctoral training in computing science with Richard S. Sutton, PhD, at the University of Alberta.
Pilarski says his team aims to make prostheses feel and respond more like a biological limb or easy-to-use functional extension of the body. O&P ALMANAC | NOVEMBER 2019
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PRINCIPAL INVESTIGATOR
and science, as well as a broad range of patients and clinical practitioners. This approach “creates impact” for O&P patients, clinicians, and families—especially those patients with upper-limb amputations, he says.
Interests Inside and Outside the Research World
As machine learning becomes more integrated with consumer technology, Pilarski hopes to extend its use to prosthetics.
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to Pilarski. This arrangement allows Pilarski and his interdisciplinary team “to cultivate the full cycle of innovation, with needs and ideas flowing from the clinic to the laboratory and back to the clinic, supported by both blue-sky university research and the Glenrose Hospital’s commitment to … academic teaching, research, and technology adoption,” says Pilarski. He devotes a great deal of time to working with graduate and undergraduate students. He ensures that the students work regularly with colleagues from medicine, engineering,
Several of the projects in the Bionic Limbs for Improved Natural Control (BLINC) Lab require custom-built prototypes, to meet specific requirements that are unavailable commercially.
PHOTOS: Patrick Pilarski, PhD
“My training is in electrical and computer engineering, and computing science, with a focus on a family of computing technologies known broadly by the names artificial, or machine, intelligence and machine learning,” Pilarski explains. Machine intelligence and machine learning are now in wide use within consumer technology, from cellphones and Internet applications to vehicles and appliances: “They represent powerful, general tools to help support people in perceiving the world around us, acting in that world, and making decisions to advance our short- and long-term goals,” says Pilarski. “For me, applying myself to multidisciplinary work on O&P problems … was a natural fit, and the best way to make significant, simultaneous progress on both the fundamental science of machine intelligence and its application to some of the hardest problems facing us as a society.” In his current role, Pilarski benefits from the University of Alberta’s close relationship with healthcare delivery in the province of Alberta. The university’s Division of Physical Medicine and Rehabilitation is based both on the Alberta campus and in the Glenrose Rehabilitation Hospital—Canada’s largest free-standing site for comprehensive tertiary rehabilitation, according
Pilarski attributes his enjoyment of his O&P work to “the diversity of people I get to interact with on a day-to-day basis in the process of moving our research forward as a team.” He describes his laboratory as “a whirlwind of activity,” and he is constantly crossing paths with other researchers, trainees, and research participants from a variety of backgrounds, perspectives, and skill sets—which makes time in the lab “both engaging and a constant opportunity for personal growth.” Pilarski devotes some of his “down time” to less technical hobbies. “After a week of staring at computer screens and working with robot hands, I sometimes get ‘hands on’ in a different way—as a blacksmith to forge tools and decorations out of red-hot iron,” he says. “The only metal-work aesthetic I can consistently create, however, is ‘rustic.’” Pilarski also enjoys outdoor pursuits—despite the cool northern temperatures. “Because Canada is clearly not cold enough for me,” Pilarski says, “I have gone scuba diving with leopard seals along the Antarctic peninsula in subzero water.”
PRINCIPAL INVESTIGATOR
Innovating for the Future
Pilarski is hopeful that upper-limb amputees will benefit from increased control and function as advances in O&P allow for integration of artificial intelligence. “Any advanced technology used in prosthesis control or feedback should ideally start by performing as well as the current gold-standard approach, and then incrementally improve through use,” he says. “As designers and researchers, when we change an intervention, we have the intent that our idea or solution will improve life for the future users of our technology in one or more ways,” he adds. “However, quantifying and truly understanding the impact that changes to the design, control, or human-facing interactions of an assistive rehabilitation device have to the relationship a person forms with their technology remains and open, pressing problem. By developing new ways to study the complex interactions between a person and a changing, adapting O&P device, we will open up the path for even more functional interventions and solutions in the years to come.”
Notable Works Patrick Pilarski, PhD, is the author or co-author of more than 80 peerreviewed articles and has been supported by provincial, national, and international research grants. Some of his most impactful published contributions include the following: • Brenneis, D.J.A., Dawson, M.R., Tanikawa, H., Hebert, J.S., Carey, J.P. Pilarski, P.M. “The Effect of an Automatically Levelling Wrist Control System.” IEEE-RAS-EMBS International Conference on Rehabilitation Robotics 24-28 June, 2019; Toronto, Canada, 816-823. • Hebert, J.S., Boser, Q.A., Valevicius, A.M., Tanikawa, H., Lavoie, E.B., Vette, A.H., Pilarski, P.M. Chapman, C.S. “Quantitative Eye Gaze and Movement Differences in Visuomotor Adaptations to Varying Task Demands Among Upper-Extremity Prosthesis Users.” JAMA Network Open 2019; 2 (9), e1911197-e1911197. • Edwards, A.L., Dawson, M.R., Hebert, J.S., Sherstan, C., Sutton, R.S., Chan, K.M. Pilarski, P.M. “Application of Real-Time Machine Learning to Myoelectric Prosthesis Control: A Case Series in Adaptive Switching.” Prosthetics & Orthotics International 2016; 40 (5), 573–581, 2016. doi: 10.1177/0309364615605373.
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MEMBER SPOTLIGHT
Blue Ridge Prosthetics & Orthotics
Spreading Joy in Patient Care Sole practitioner prioritizes patients while managing business operations in Virginia
I
NDI HEWAVITA, CP, BOCO,
worked for several O&P facilities after earning his degree at California State University, Dominguez Hills, and completing his residency. “After working many years for a large company, I moved to Napa Valley Prosthetics and Orthotics in California, where the owner there really opened my eyes to what patient care—especially prosthetic care—can look like,” Hewavita says. “He looked at patients as people with limb loss rather than as a source of revenue. He also showed me how he can take care of his employees by not only being their boss but also being their friend and making them feel valued and important.”
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facility since its start in 2018. “I was eager to apply the philosophy I learned in Napa.” Blue Ridge P&O occupies about 1,500 square feet and is accessed via a large lobby with OWNER: an open, welcoming feel, and Jay Kurelich, CFo an easily accessible ramp from the parking lot to the lobby. The LOCATION: facility features a large patient Harrisonburg, Virginia room, a waiting area, a stock room, and a small lab for adjustHISTORY: ments. Hewavita outsources fabrication, working closely with 1.5 years Össur and other providers. Existing patients provide the bulk of marketing for the facility. “Word of mouth is so much better than formal marketing,” says Hewavita. “Especially with prosthetics, patients who are happy with our work will share their experiences on social media—and that leads to new patients.” Starting a facility from the ground up proved to be hard work,
FACILITY: Blue Ridge Prosthetics & Orthotics
especially because the birth of the fourth Hewavita baby coincided with the launch. “It’s been a journey,” admits Hewavita, who endured many sleepless nights. “This last year or so has been one of the hardest of my life, and my wife was incredibly supportive. But the result is that I am more resilient and even more committed to fighting for my patients.” Being a sole practitioner with only one administrative employee means that Hewavita juggles running the facility while caring for patients. “I don’t want to compromise patient care or the time they deserve to focus more on the business operations,” he says. “That’s been the hardest lesson.” Over the past few months, things have started to come together, he says. Now that Hewavita is finding his footing, he wants to start programs that would connect patients with one another. “New patients are often very depressed. They can’t see the other side of losing a limb,” he says. “Getting new patients in touch with other amputee patients who are at different stages of life can inspire and motivate them. Bringing patients together and having conversations only produces better outcomes.” Eventually, Hewavita wants to hire additional practitioners and office staff. “I want to bring in people who have a passion to work, not to look at it as just an 8-to-5 job. Each of us is given gifts, and we have to be able to employ those gifts to their full potential with joy,” he says. “I love to hear my patients and co-workers laugh even on the hardest days,” and know that they feel they belong. “The saying is, ‘Treat patients the way you want to be treated,’” Hewavita says. “I want to extend that to treating employees the same way.” Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net.
PHOTOS: Blue Ridge Prosthetics & Orthotics
Hewavita knew he wanted to run an O&P facility using those principles, and the opportunity arose after he and his wife, Kimberly, moved to her home state of Virginia in 2013. Hewavita eventually found himself at Specialized Orthopaedic Services in Vienna, Virginia. “The owner, Jay Kurelich, CFo, saw that I’d like to be closer to family and let me partner and open Blue Ridge Prosthetics & Orthotics in Harrisonburg, Virginia,” says Hewavita, who has run the new
Indi Hewavita, CP, BOCO, works on a diagnostic prosthetic fitting for patient G. Watkins.
By DEBORAH CONN
MEMBER SPOTLIGHT
PEL LLC
By DEBORAH CONN
Distributor Dedication PEL’s owner emphasizes meeting clinicians’ needs to improve patient outcomes
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OST O&P PROFESSIONALS
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Michael Sotak
COMPANY: PEL LLC OWNER: Michael Sotak LOCATION: Cleveland, Ohio HISTORY: 60 years
PEL has been at the same location in Cleveland since 1984, but the campus has nearly doubled in size since then. It houses administrative, sales, sales support, IT, finance, marketing, and warehouse operations. PEL carries more than 300,000 products from at least 300 companies, shipping them from one location. Sotak finds that customers prefer receiving their orders in one shipment whenever possible, rather than from multiple locations. Given PEL’s central location, employees can service customers’ needs effectively and efficiently without the added cost of multiple warehouses and redundant inventory, Sotak explains. PEL offers drop-ship services when necessary to meet a customer’s need-by date. When Sotak first purchased the business, he made significant changes to the PEL website to make it more efficient and user-friendly. The site, like those of the company’s competitors, offered an online catalog for orders, with devices listed under each manufacturer. “Every facility had to look under each manufacturer to find and compare what they were looking for. It was a time-consuming and often confusing process,” says Sotak. “We modified the system so practitioners could
Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net.
PHOTO: PEL LLC
are familiar with PEL, the first major distributor of O&P products. The company was founded in 1959 by Paul E. Leimkuehler, CPO, who had lost his leg above the knee at the Battle of the Bulge in World War II. He opened a patient-care facility in Cleveland in 1949, and in 1955 he began distributing Ottobock components nationwide. Leimkuehler incorporated PEL Supply Co. in 1959, creating the name from his initials, and, eventually, his three sons and his daughter took ownership. In July 2013, Michael Sotak acquired the business. “Prior to that, I had been an executive at Invacare,” a large manufacturer of durable medical equipment, he notes. “I was looking for a new opportunity, and when PEL became available, I decided to become an entrepreneur.” Sotak’s business strategy has been to capitalize on PEL’s brand equity and accomplished history—PEL is currently the third largest O&P distributor in the country—and focus on the driving principle of superior service. “Our tagline is ‘the service you deserve,’ and we mean it,” says Sotak. “We have made multiple improvements in warehouse efficiency, and I believe our fill rates—about 98 percent—are about the highest in the industry. We are totally focused on providing the best possible customer experience.”
search by clinical need rather than by manufacturer.” Now, if a CP searches for a prosthetic foot, he or she can view devices produced by all manufacturers. This was a revolutionary change, and other distributors quickly followed suit, according to Sotak. PEL focuses on two goals, he says: helping practitioners achieve the best and fastest clinical outcomes and helping them improve efficiency and cost management, so they also get the best economic outcomes. The company has invested heavily in technology, and its catalog is fully integrated with different types of O&P practice software. PEL uses traditional marketing methods, including print and digital advertising, direct email marketing, and industry trade shows. The company communicates with customers through digital and print “PELegrams,” bulletins that highlight new products and company activities. Seeking ways to improve the company, Sotak commissioned two market research studies with independent consultants. “We were pleased with the results,” says Sotak. “PEL was the distributor most likely to be recommended by someone. We excelled in most of the 28 attributes in study: We were the easiest to work with, the most trustworthy, the best overall value, and the best website,” according to the commissioned studies. “We’re not the biggest, but we strive to provide the best overall service to our practitioners,” says Sotak. “We do whatever we can to understand what they need for better patient care and better outcomes. Our plan is to out-service our competition.”
AOPA NEWS
Co-OP
Don’t Sleep on the Latest AOPA Member Resource: AOPA Co-OP Are you utilizing your AOPA membership to its fullest? Be sure to visit the AOPA Co-OP at www.aopanet.org/ resources/co-op/. A Wikipedia for all things O&P, the Co-OP is a one-stop resource for information about reimbursement, coding, and policy. It is a searchable database that provides up-to-date information on developments in Medicare policy, state-specific legislation, private payor updates, and more. Members can access detailed information on everything from modifiers to product-specific L codes and associated policies. Additionally, members can share information and insights on developments impacting the entire O&P profession.
If you haven't signed up for the Co-OP yet, take part in a free live tutorial on the following date: • Friday, December 6 at noon EST.
This is your opportunity to learn about O&P's most comprehensive resource for coding, billing, and reimbursement. Ashlie White, AOPA’s director of strategic initiatives, will demonstrate how to use the Co-OP and answer all of your questions. Contact Betty Leppin, bleppin@aopanet.org, for details.
NOVEMBER 13
AOPAversity Webinars During the one-hour monthly webinars, AOPA experts provide the most up-to-date information on a specific topic. Webinars are held the second Wednesday of each month at 1 p.m. EST. One registration is all it takes to provide the most reliable business information and CE credits for your entire staff. If you’ve missed a webinar, AOPA will send you a recording of the webinar and quiz for CE credits, so you can still take advantage of the series discount and the valuable learning opportunities. Sign Up & Save! Registration Fee
Price Per Seminar
AOPA Members $99.00* Nonmembers $199.00*
* Includes an unlimited number of participants per telephone line. AOPA members may use code “member” when registering for the $99 price.
Earn 1.5 Business CEs each by returning the provided quiz within 30 days and scoring at least 80 percent. All webinars begin at 1 p.m. EST. Webinar registration fees are nonrefundable. AOPA can provide the webinar recording if registrants cannot make the scheduled webinar.
FREE
TUTORIAL
UPCOMING WEBINAR
The Holiday Season—How To Provide Compliant Gifts ’Tis almost the season to be jolly! Learn the right way to demonstrate your appreciation to patients and referral sources while adhering to the guidelines surrounding gift giving. The November 13 webinar will explore the following topics: • When are gifts to referral sources acceptable? • When are gifts to patients acceptable? • What do you need to know about the federal antikickback regulations? • What are some tips for creating a compliant gift-giving policy?
DECEMBER 11
UPCOMING WEBINAR
New Codes for 2020, Other Updates, and Yearly Roundup Get ready for 2020 by learning about the new codes and fees to be implemented next year! AOPA experts also will review the important coding and billing reminders from 2019 and preview upcoming policy changes. All of your questions will be answered: • How are new codes created? • How are fees established? • When are policies updated? • And much more!
O&P ALMANAC | NOVEMBER 2019
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O&P PAC UPDATE
T
HE O&P PAC UPDATE provides information on the activities of the
O&P PAC, including the names of individuals who have made recent donations to the O&P PAC and the names of candidates the O&P PAC has recently supported. The O&P PAC recently received donations from the following AOPA members*:
Jacqueline Adolph, CO
Colton Graham
Thomas Metheney, CTO
John Angelico, CP
Paul Gudonis
Jonathan Naft, CPO
Maggie Baumer, JD
Kimberly Hanson
Kathleen Pelz
Jenna Baxter
Bob Harmon
Dale Perkins
David Boone, BSPO, MPH, PhD
David Henry
Joyce Perrone
Deborah Boone
Michele Hogan Dan Ignaszewski
Joseph Pongratz, CPO, FAAOP
Mark Brady Jeffrey M. Brandt, CPO J. Douglas Call, CP Erin Cammarata Kristin Carnahan, CPO, FAAOP Sarah Chang Glenn Crumpton, CPO Kathleen DeLawrence
David Johnson, CO Jim Kaiser, CP, LP Karyn Kessler
Bradley Ruhl Kurt Schlau Robin Seabrook
Jim Kingsley, COO
Michael Sotak
Charles Kuffel, CPO, FAAOP
Jack Steele, CO Wanda Stephans
Teri Kuffel, JD
Natalie Stewart, CPO
William Leimkuehler, CPO, LPO
Robert Tuck, CPO
Thomas DiBello, CO, LO, FAAOP
Kyle Leister, CPO, LPO
Jason Wening, CPO, FAAOP
John Chad Duncan, PhD, CPO
Ron Longo, CP
Mark Woodson, RTP
Pam Lupo, CO
Larry Word, CPO
Lee Mantelmacher, CPO
Shane Wurdeman, MSPO, PhD, CP, FAAOP
Frank Erdeljac, CO Kirk Ferris, CPO Steven Filippis, CP Jim Fitzpatrick
Stuart Marquette, CO Brad Mattear, LO, CPA, CFo
Jessica Zistatsis, MSME
Brian Mayle
The purpose of the O&P PAC is to advocate for legislative or political interests at the federal level that have an impact on the orthotic and prosthetic community. The O&P PAC achieves this goal by working closely with members of the House and Senate and other officials running for office to educate them about the issues, and
AOPA also would like to thank the following individuals for their recent contributions to Captiol Connections and/or an O&P PACsponsored event: Rudy Becker David Boone, BSPO, MPH, PhD Jeffrey M. Brandt, CPO Thomas Costin Mark Ford Randall McFarland, CPO
help elect those individuals who support the orthotic and prosthetic community. To participate in, support, and receive additional information about the O&P PAC, federal law mandates that eligible individuals must first sign an authorization form, which may be completed online: bit.ly/aopapac.
Rick Riley Paul Weber, CO Jason Wening, CPO, FAAOP
*This list was created on Oct. 7, 2019, and includes only donations and contributions made or received between Sept. 16, 2019, and Oct. 7, 2019. Any donations or contributions made or received on or after Oct. 7, 2019, will be published in a future issue of O&P Almanac.
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NOVEMBER 2019 | O&P ALMANAC
CAREERS
Opportunities for O&P Professionals
Pedorthist, Orthotic Tech, Shoe Cobbler/Tech
Job location key:
Sacramento, California Independent Sacramento Orthotic and Pedorthic facility now hiring experienced talent for the following positions: • ABC Pedorthist WE ARE HIRING • ABC Orthotic Tech COME JOIN OUR TEAM • Shoe Cobbler/Tech
- Northeast - Mid-Atlantic - Southeast - North Central - Inter-Mountain - Pacific
Hire employees and promote services by placing your classified ad in the O&P Almanac. When placing a blind ad, the advertiser may request that responses be sent to an ad number, to be assigned by AOPA. Responses to O&P box numbers are forwarded free of charge. Include your company logo with your listing free of charge. Deadline: Advertisements and payments need to be received one month prior to publication date in order to be printed in the magazine. Ads can be posted and updated any time online on the O&P Job Board at jobs.AOPAnet.org. No orders or cancellations are taken by phone. Submit ads by email to ymazur@AOPAnet.org or fax to 571/431-0899, along with VISA or MasterCard number, cardholder name, and expiration date. Mail typed advertisements and checks in U.S. currency (made out to AOPA) to P.O. Box 34711, Alexandria, VA 22334-0711. Note: AOPA reserves the right to edit Job listings for space and style considerations. O&P Almanac Careers Rates Color Ad Special 1/4 Page ad 1/2 Page ad
Member $482 $634
Listing Word Count 50 or less 51-75 76-120 121+
Member Nonmember $140 $280 $190 $380 $260 $520 $2.25 per word $5 per word
Nonmember $678 $830
ONLINE: O&P Job Board Rates Visit the only online job board in the industry at jobs.AOPAnet.org. Job Board
Pacific
Member Nonmember $85 $150
Must be a team player with a great attitude and have the ability to communicate effectively. Must be responsible and able to work independently. We hope to hear from you! Send résumés to: Email: Mike@streamlineorthopedic.com
WANTED! A few good businesses for sale. Lloyds Capital Inc. has sold over 150 practices in the last 26 years. If you want to sell your business or just need to know its worth, please contact me in confidence. Barry Smith Telephone: (O) 323/722-4880 • (C) 213/379-2397 Email: loyds@ix.netcom.com
AOPA Supplier Plus Partners Thank you to our AOPA Supplier Plus Partners for their continued support of the association.
For more opportunities, visit: http://jobs.aopanet.org.
SUBSCRIBE
A large number of O&P Almanac readers view the digital issue— If you’re missing out, apply for an eSubscription by subscribing at bit.ly/AlmanacEsubscribe, or visit issuu.com/americanoandp to view your trusted source of everything O&P.
COMPLETE CONTROL
O&P ALMANAC | NOVEMBER 2019
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MARKETPLACE
Feature your product or service in Marketplace. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net. Visit bit.ly/almanac19 for advertising options.
ALPS Smart Seal Liner Our Smart Seal Liner features raised bands that grip to the socket wall to form a secure interface. The bands are coated to ensure longer life and extra security for a smarter seal. The Smart Seal Liner has a new seamless knitted construction with a modern look and is available in locking and cushion suspension. The locking version features a new distal construction to control distal distraction with no matrix. The Smart Seal Liner is just what you need to achieve great suspension! Call us at 800/574-5426 or visit www.easyliner.com for more information.
Apis
Sutti Bounders Store & Return Energy— Mimicking Normal Muscle Function New “Sutti Bounders” modular pediatric dynamic elastomers are a patent-pending elastomer technology that offer two progressive solutions. Sutti Bounders store and return energy—mimicking normal muscle function to produce both eccentric and concentric contractions and, if needed, a ground-reaction force. Smart and simple modular design, standardized sizes, and three levels of performance to choose from add up to an easy-to-use expandable dynamic system to treat your pediatric and young adult patient base. For more information, visit www.fabtechsystems.com/ bounders or call 800/322-8234.
LEAP Balance Brace
Apis custom program offers practitioners best options and services for patient compliance. All products are covered under risk-free guaranteed-fit promise. We stand firmly behind our words. Call us at 1-888/937-2747.
The Original Preflexed Suspension Sleeve ESP created the Flexi family of suspension sleeves as a comfortable, durable, and cost-effective alternative to traditional suspension sleeves. Preflexed at 43 degrees for maximum comfort and natural unrestricted movement. For more information, call ESP LLC at 888/932-7377 or visit www.wearesp.com. 46
NOVEMBER 2019 | O&P ALMANAC
Hersco’s Lower-Extremity Ankle Protection (LEAP) brace is designed to aid stability and proprioception for patients at risk for trips and falls. The LEAP is a short, semirigid ankle-foot orthosis that is functionally balanced to support the foot and ankle complex. It is fully lined with a lightweight and cushioning Velcloth interface, and is easily secured and removed with two Velcro straps and a padded tongue. For more information, call 800/301-8275 or visit www.hersco.com.
Naked Prosthetics Naked Prosthetics designs and manufactures high-quality prosthetic devices specifically for finger loss. Our mission is to assist people with digit amputation(s) and positively impact their lives with fully articulating, custom finger prostheses. Our product aims to restore the ability to perform most tasks, supporting job retention and an active lifestyle. Our customers have lost fingers to power tools, equipment malfunctions, injury in the line of military service, random accidents, and infections; in some cases, multiple digits have been lost. NP provides a viable functional prosthesis, as opposed to a passive cosmetic solution. Our design mimics finger motion and utilizes the remainder of an amputee’s digit to power the device. For more information, visit www.npdevices.com.
MARKETPLACE Arizona AFO’s Moore Balance Brace Check out the latest peer-reviewed, published study substantiating the efficacy of Arizona AFO’s Moore Balance Brace. This randomized controlled trial investigated the long-term impact of a balance ankle-foot orthosis, the Moore Balance Brace, on balance, fear of falling, and physical activity in older adults. Researchers reported not only a decrease in fall risk, but a meaningful reduction in fear of falling, leading to an increase in physical activity. Check out the full study at arizonaafo.com/baylor.
Proprio Foot® Because the world isn’t flat. Proprio Foot® debuted in 2006 with a simple goal: to reduce trips and falls. This latest-generation microprocessor ankle, built upon a Pro-Flex® LP foot module, provides 44 percent more toe-off power— taking us one step closer to our goal. Visit ossur.com/proprio-foot to learn more.
Discover PROTEOR USA
Delivering an extensive, progressive product line that includes everything today’s active amputees need to live the life they love. Offering an innovative portfolio that includes everything from the virtually indestructible RUSH Foot collection to the world’s first microprocessor-controlled hydraulic four-bar knee with both stance and swing functionality, the ALLUX. The EASY RIDE, multiuse extreme sports knee, to the KEASY, renowned prefabricated cones. The K2 GERY foot, to the flexible, all-terrain, DynaTrek foot. Discover the exciting PROTEOR USA product line today! A whole new look. A whole new vibe. A whole new world. #HumanFirst. Visit us at proteorUSA.com.
Ottobock’s CCAFO Provides Robust Stability and Support Ottobock’s expertise in custom orthotic fabrication and carbon composites come together to produce an inspiring custom ankle-foot orthosis (AFO). Crafted from carbon prepreg, this lightweight and low-profile AFO provides a solution for individuals with plantarflexion weakness and those needing triplanar support for the foot and ankle. The design stores and returns energy for propulsion while providing function of the soleus muscle and third rocker mechanics (heel-off). This latest addition to the Ottobock line of AFOs is custom-made to match your patient’s specific height, weight, and activity level. For more information, call 800-328-4058 or visit professionals.ottobockus.com.
New: Ottobock’s Triton Side Flex Your will. Your way. The latest member of the Triton foot family helps your patients feel more confident with its unique degree of side-to-side flexbility and safe, full-ground contact—including on uneven surfaces. The M-L unit reduces the sideward tilting moments on the knee or in the socket. Simultaneously, compensatory movements can be minimized. • • • •
i-
Comfortable adjustment for increased sense of security Dynamic rollover supports vigorous walking Delivers the performance suited to each step Supports agile and high-impact movement across varying terrain conditions. Visit professionals.ottobockus.com to learn more.
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MARKETPLACE Spinal Technology Inc. Spinal Technology Inc. is a leading central fabricator of custom spinal and scoliosis orthoses. Our ABC-certified staff orthotists collaborate with our highly skilled, experienced technicians to provide the highest quality products and fastest delivery time, including weekends and holidays, as well as unparalleled customer support in the industry. Spinal Technology is the exclusive manufacturer of the Providence Nocturnal Scoliosis® System, a nocturnal bracing system designed to prevent the progression of scoliosis, and the patented FlexFoamTM spinal orthosis. For information, contact 800/253-7868 or visit www.spinaltech.com.
JAWS VO PREHENSOR JAWS is a high-performance, voluntary opening, prosthetic terminal device operated with or without a cable. JAWS's gripping force is easily user adjustable, utilizing proven “vector” technology. JAWS has a prehensile, not a hook, configuration for better control of ATVs, motorcycles, snowmobiles, personal watercraft, and lawn mowers, as well as working tools, domestic, garden, and yard tool handles. It snaps on and off objects with variable gripping forces exceeding 50 pounds. Additionally, JAWS features an integral, friction adjustable, radial-ulnar pivot. TRS is BODY POWER. For more information, 800/279-1865 or visit trsprosthetics.com.
The Xtern Foot Drop AFO From TurboMed Orthotics This unique ankle-foot orthosis (AFO) was designed for patients suffering from foot drop. It is worn 100 percent outside of the shoe. The Xtern is HCPCS Code L1951 Validated. Turbomed innovative products are now available through distributor partnerships in more than 26 countries. Its unique design and material composition give another meaning to walking and running. There is no limitation with the Xtern for the customers—not even a weight limit! For orthotists and professionals, a trial kit called AT (assessment tool) is available to quickly and easily assess patient compatibility with the Xtern in less than five minutes. Available in USA from Cascade Supply, SPS, Lakes Medical Innovations, Kevin Orthopedic, and Physio Tech. For more information, visit www.turbomedorthotics.com.
2019 AOPA Coding Products Get your facility up to speed, fast, on all of the O&P HealthCare Common Procedure Coding System (HCPCS) code changes with an array of 2019 AOPA coding products. Ensure each member of your staff has a 2019 Quick Coder, a durable, easy-to-store desk reference of all of the O&P HCPCS codes and descriptors. • 2019 Coding Suite (includes CodingPro single user, Illustrated Guide, and Quick Coder): $350 AOPA members, $895 nonmembers • 2019 Quick Coders: $30 AOPA members, $80 nonmembers Order at www.AOPAnet.org or call AOPA at 571/431-0876.
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NOVEMBER 2019 | O&P ALMANAC
CALENDAR
APPLY ANYTIME! BOC Certification. Apply anytime and www.bocusa.org test when ready for the orthotic fitter, mastectomy fitter, and DME specialist certifications. To learn more about BOC’s nationally recognized, in-demand credentials and to apply today, visit www.bocusa.org.
Cascade Dafo Institute
Eight free ABC-approved online continuing education courses for pediatric practitioners. Take anytime, anywhere, and earn up to 11.75 CE credits. Visit cascadedafo.com or call 800/848-7332.
December 11
New Codes for 2020, Other Updates, and Yearly Roundup. Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR
December 12–14
Pediatric Gait Analysis and Orthotic Management: An Optimal Segment Kinematics and Alignment Approach to Rehabilitation (OSKAR). Chicago. 25.5 ABC credits. For more information, contact Melissa Kolski at 312/238-7731 or visit www.sralab.org/academy/PedsGait19.
2020
2019
January 1
November 13
The Holiday Season—How To Provide Compliant Gifts. Register online at bit.ly/ 2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR
December 1
ABC: Application Deadline for February Certification Exams. All practitioner candidates have an additional 30 days after the application deadline to complete their residency. Contact 703/836-7114, email certification@ABCop.org, or visit ABCop.org/certification.
December 1
ABC: Practitioner Residency Completion Deadline for Winter CPM Exams. All practitioner candidates have an additional 30 days after the application deadline to complete their residency. Contact 703/836-7114, email certification@ABCop.org, or visit ABCop.org/certification.
ABC: Practitioner Residency Completion Deadline for February Exams. All practitioner candidates have an additional 30 days after the application deadline to complete their residency. Contact 703/836-7114, email certification@ABCop.org, or visit ABCop.org/certification.
January 8
Modifiers: Enhance Your Claims Two Letters at a Time. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR
January 10–11
ABC: Orthotic Clinical Patient Management (CPM) Exam. ABC Testing Center, Tampa, FL. Contact 703/8367114, email certification@ABCop.org, or visit ABCop.org/certification.
January 17–23
US ISPO Pac Rim Meeting. Sheraton Maui Resort & Spa, Lahaina, Maui, HI. Visit www.usispo.org.
January 24–25
December 9–14
ABC: Written and Simulation Certification Exams. ABC certification exams will be administered for orthotists, prosthetists, pedorthists, orthotic fitters, mastectomy fitters, therapeutic shoe fitters, orthotic and prosthetic assistants, and technicians in 350 locations nationwide. Contact 703/836-7114, email certification@ABCop.org, or visit ABCop.org/certification.
ABC: Prosthetic Clinical Patient Management (CPM) Exam. ABC Testing Center, Tampa, FL. Contact 703/8367114, email certification@ABCop.org, or visit ABCop.org/certification.
February 1
ABC: Application Deadline for Certification Exams. Applications must be received by February 1 for individuals seeking to take the April Written and Simulation certification exams. Contact 703/836-7114, email certification@ABCop.org, or visit ABCop.org/certification.
O&P ALMANAC | NOVEMBER 2019
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CALENDAR
February 10–11 SEMINAR
rgleeson@AOPAnet.org.
Coding & Billing Seminar. Las Vegas. For more information, email Ryan Gleeson at
March 10
New Technical Credits—Clinician’s Corner: Orthotics. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR
February 10–15
ABC: Written and Simulation Certification Exams. ABC certification exams will be administered for orthotists, prosthetists, pedorthists, orthotic fitters, mastectomy fitters, therapeutic shoe fitters, orthotic and prosthetic assistants and technicians in 350 locations nationwide. Contact 703/836-7114, email certification@ABCop.org, or visit ABCop.org/certification.
March 19–21
Georgia Society of O&P. Alpharetta, GA. Visit www.georgiasop.com.
April 8 WEBINAR
rgleeson@AOPAnet.org.
A Policy Review: LSO/TLSO. For more information, email Ryan Gleeson at
February 12
O&P Coding & Billing Myths: The Truth Out There. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR
February 14–15
PrimeFare Central Regional Scientific Symposium. Renaissance Hotel and Convention Center, Tulsa, OK. For more information, visit www.primecareop.com, call 888/388-5243, or email primecarepruitt@gmail.com.
April 23–25
International African–American Prosthetic Orthotic Coalition Annual Meeting. The Shriners Hospital for Children-Houston. Houston. For more information, contact Amandi Rhett at 404/754-4337, email arhett1@gmail.com, or visit www.iaapoc.org.
April 27–28 SEMINAR
at rgleeson@AOPAnet.org.
Coding & Billing Seminar. Charlotte, NC. For more information, email Ryan Gleeson
Statement of Ownership, Management and Circulation (required by U.S.P.S. Form 3526) 1. Publication Title: O&P Almanac 2. Publication No.: 1061-4621 3. Filing Date: 9/24/19; revised 11/8/19 4. Issue Frequency: Monthly 5. No. of Issues Published Annually: 12 6. Annual Subscription Price: $59 domestic/$99 foreign 7. Complete Mailing Address of Known Office of Publication (Not Printer): American Orthotic & Prosthetic Association, 330 John Carlyle St., Suite 200, Alexandria, VA 22314 8. Complete Mailing Address of Headquarters or General Business Office of Publisher (Not Printer): Same as #7 9. Full Names and Complete Mailing Addresses of Publisher, Editor, and Managing Editor: Publisher: Eve Lee, address same as #7. Editor: Josephine Rossi, Content Communicators LLC, PO Box 938, Purcellville, VA 20132. 10. Owner (Full Name and Complete Mailing Address): American Orthotic & Prosthetic Association, same as #7 11. Known Bondholders, Mortgagees, and Other Security Holders Owning 1 Percent or More of Total Amount of Bonds, Mortgages, or Other Securities: None. 12. The purpose, function, and nonprofit status of this organization and the exempt status for federal income tax purposes: Has Not Changed During the Preceding 12 Months. 13. Publication Name: O&P Almanac 14. Issue Date for Circulation Data Below: August 2019 Avg. No. Copies Each Issue During Preceding 12 Months 15. Extent and Nature of Circulation: a. Total number of Copies (Net Press Run) b. Paid and/or Requested Circulation (1) Paid or Requested Outside-County Mail Subscriptions (2) Paid In-County Subscriptions (3) Sales Through Dealers and Carriers, Street Vendors, Counter Sales, and other non-USPS Paid Distribution (4) Other Classes Mailed through the USPS c. Total Paid and/or Requested Circulation d. Free Distribution by Mail (1) Outside-County as Stated on Form 3541 (2) In-County as Stated on Form 3541 (3) Other Classes Mailed through the USPS (4) Free or Nominal Rate Distribution Outside the Mail e. Total Free or Nominal Rate Distribution f. Total Distribution g. Copies not Distributed h. Total i. Percent Paid and/or Requested Circulation
50
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No. Copies of Single Issue Published Nearest to Filing Date
11,530
11,242
10,899.64 0 44.36
10,864 0 44
5.18 10,949.18
5 10,913
0 0 0 422.91 422.91 11,372.09 157.91 11,530 97%
0 0 0 130 130 11,043 199 11,242 99%
CALENDAR
May 5–6
AOPA Policy Forum. Washington, DC. Visit www.AOPAnet.org.
July 8
The ABCs of Appeals: Know the Players and Get the Tips. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR
May 13
Social Media Mayday: Increase Your Footprint. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR
May 13–15 NYSAAOP Meeting. Schenectady, NY. Visit www.nysaaop.org/meeting.
July 31–August 1
PrimeFare East Regional Scientific Symposium. Renaissance Hotel and Convention Center, Downtown Nashville. For more information, visit www.primecareop. com, call 888/388-5243, or email primecarepruitt@gmail.com.
August 12
Contracting 101: Understanding the Basics. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR
June 10
New Technical Credits—Clinician’s Corner: Prosthetics. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR
Calendar Rates CE For information on continuing education credits, contact the sponsor. Questions? Email ymazur@AOPAnet.org. CREDITS
September 9–12
AOPA National Assembly. Mandalay Bay, Las Vegas. For general inquiries, contact Ryan Gleeson at 571/431-0836 or rgleeson@AOPAnet.org, or visit www.AOPAnet.org.
Let us share your next event! Phone numbers, email addresses, and websites are counted as single words. Refer to www.AOPAnet.org for content deadlines. Send announcement and payment to: O&P Almanac, Calendar, P.O. Box 34711, Alexandria, VA 22334-0711, fax 571/431-0899, or email ymazur@AOPAnet.org along with VISA or MasterCard number, the name on the card, and expiration date. Make checks payable in U.S. currency to AOPA. Note: AOPA reserves the right to edit calendar listings for space and style considerations.
Words/Rate
Member
Nonmember
25 or less
$40
$50
26-50
$50 $60
51+
$2.25/word $5.00/word
Color Ad Special 1/4 page Ad
$482
$678
1/2 page Ad
$634
$830
AD INDEX
Advertisers Index Company ALPS South LLC Amfit Apis Footwear Company ESP LLC Fabtech Systems LLC Hersco Naked Prosthetics OHI Össur Americas Inc. Ottobock PROTEOR USA Spinal Technology Inc. TRS TurboMed Orthotics
Page Phone 33 800/574-5426 17 800/356-3668 19 888/937-2747 5 888-WEAR-ESP 21 800-FABTECH 1 800/301-8275 7 888/977-6693 11 877/780-8382 3 800/233-6263 C4 800/328-4058 C2 855/450-7300 9 800/253-7868 23 800/279-1865 41 888/778-8726
Website www.easyliner.com www.amfit.com www.apisfootwear.com www.wearesp.com www.fabtechsystems.com www.hersco.com www.npdevices.com www.ohi.net www.ossur.com www.professionals.ottobockus.com www.proteorusa.com www.spinaltech.com www.trsprosthetics.com www.turbomedorthotics.com O&P ALMANAC | NOVEMBER 2019
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ASK AOPA CALENDAR
Patient Payment Processes How to waive copays, collect out-of-pocket payments, and more What is Medicare’s reasonable useful lifetime (RUL) for orthotics and prosthetics?
Q/
The RUL for orthotics and prosthetics is determined by program instructions from Medicare. When there are no program instructions, the durable medical equipment Medicare administrative contractors (DME MACs) may establish RULs for orthotics and prosthetics, but no RUL can be more than five years. In other words, if Medicare does not establish a RUL for an item, the DME MACs may create a RUL through policy; if the DME MACs don’t create a policy, the RUL for an item is set at five years. Prosthetics have a RUL that is less than five years. Through the Benefits Improvement and Protection Act (BIPA) 2000, Medicare has provided program instructions for the RUL for prosthetics. According to BIPA, “prosthetic devices which are artificial limbs” may be replaced at any time, regardless of useful lifetime, as long as the replacement is reasonable and necessary. In the External Breast Prostheses Policy, the DME MACs have established a RUL that is less than five years. A silicone breast prosthesis has a RUL of two years, and a foam, fiber, or fabric breast prosthesis has a RUL of six months. For orthoses, there are no direct program instructions from Medicare, so the RUL is set at five years. Knee orthoses are the only exceptions to the five-year orthotics RUL. In the Knee Orthoses Policy, the DME MACs have established a RUL ranging between one and three years, depending on the type of knee orthosis. Orthoses described by codes L1810–L1830 have a RUL of one year, and those with codes L1831, L1832, and L1835 have a RUL of two years. All other knee orthoses have a RUL of three years.
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AOPA receives hundreds of queries from readers and members who have questions about some aspect of the O&P profession. Each month, we’ll share several of these questions and answers from AOPA’s expert staff with readers. If you would like to submit a question to AOPA for possible inclusion in the department, email Editor Josephine Rossi at jrossi@contentcommunicators.com.
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Is there a special hardship waiver a patient should sign if we wish to waive collecting his or her copays?
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You are required to make all attempts to collect copays from beneficiaries. However, under certain circumstances, such as hardships, it is acceptable to waive copays. There is not a required or Medicareapproved document that must be filled out and signed by the beneficiary. However, you must be consistent on how you determine hardship, and you must not routinely waive copays.
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If an item is noncovered, are we required to bill Medicare? And are we required to use the advanced beneficiary notice (ABN) form?
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If an item is statutorily noncovered, meaning it is not a benefit under the Medicare program and is never paid for by Medicare, you are not obligated to bill Medicare. However, if a patient requests that you submit the claim anyway—perhaps because he or she has secondary coverage—you must submit the claim. In these cases, you should submit the claim with the GY modifier. If the item is noncovered, you are not required to have the patient sign an ABN form to shift the financial liability to the patient since noncovered items are the responsibility of the patient. However, you may use the ABN form as a way to prove that you notified the patient that the item would be noncovered and that he or she would be responsible for payment.
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If a patient wishes to pay for an item out of pocket, are we obligated to comply—or may we bill his or her insurance anyway?
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If a patient requests that you not disclose any information to his or her insurance and he or she is paying you directly and paying you in full, then you are obligated to meet the request; you may not also bill the patient’s insurance.
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