The Magazine for the Orthotics & Prosthetics Profession
F E B R UARY 2019
Increased Scrutiny on Inpatient Deliveries and Billing P.18
Exploring Alternative Revenue Streams P.32
The Benefits of Combined Clinician/ Researcher Responsibilities P.40
For What It’s Worth MARKET INSIGHTS AND TIPS FOR APPRAISING AND SELLING YOUR O&P PRACTICE P.24
RAC Audits Currently Underway P.60
E! QU IZ M EARN
2
BUSINESS CE
CREDITS
WWW.AOPANET.ORG
P.21
This Just In: Palmetto GBA Takes the Reins as PDAC Contractor P.22
YOUR CONNECTION TO
EVERYTHING O&P
THE P REMI E R M E E TI N G F O R O RT H OT IC , PR OST HET IC , AND PEDOR T HIC PR OFESSIONAL S.
Experience all the AOPA National Assembly has to offer while visiting San Diego.
Join AOPA in San Diego, known for incredible
#AOPA2019
panoramic views. Located in the downtown
ADVANCE YOUR CAREER BY SUBMITTING A PAPER.
Marina district, the San Diego Convention Center
Learn more at:
has many top attractions within walking distance.
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SOUTHERN CALIFORNIA San Diego’s unbeatable location makes it the perfect gateway providing you with outstanding opportunities for pre- and post-conference travel.
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contents
FE B R UARY 2019 | VOL. 68, NO. 2
COVER STORY
FEATURES
Acquisitions activity in the O&P space is picking up, according to O&P business experts. Business owners and management teams that are considering selling their businesses should implement strategies to ensure profitable transactions, including examining their financial statements, hiring consultants, and determining the value of their facilities. By Michael Coleman
22 | This Just In PDAC Transition
Palmetto GBA has taken over as the Pricing, Data Analysis, and Coding (PDAC) contractor. Find out who leads the organization, what duties Palmetto will be responsible for, and how to contact the PDAC going forward.
PHOTO: Blue Sky Orthotic & Prosthetics
2
24 | For What It's Worth
FEBRUARY 2019 | O&P ALMANAC
32 |
Building Value, Boosting Profits
Some O&P businesses are exploring alternative revenue streams, expanding beyond traditional orthotics and prosthetics to target specialized patient populations or position their companies as comprehensive solution providers. Learn some of the strategies being used to offer specialized sports prostheses, employ athletic trainers, increase pedorthic sales, provide central fabrication solutions, and more. By Christine Umbrell
© Össur, 02.2019
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% of amputees
have fallen in the last year
1
40
% of falls result in injury
with half needing medical attention
2
70
% reduction in falls
while using Proprio Foot3
1. Miller, William C., Mark Speechley, and Barry Deathe. “The prevalence and risk factors of falling and fear of falling among lower extremity amputees.” Archives of physical medicine and rehabilitation 82.8 (2001): 1031-1037. 2. Kaufman, K. Risk factors and costs associated with accidental falls among adults with above-knee amputations: a population-based study. American Orthotic and Prosthetic Association 2016.(Mayo Clinic). http://www.aopanet.org/resources/research/ 3. Ludviksdottir A, Gruben K, Gunnsteinsson K, Ingvarsson Th, Nicholls M. Effects on user mobility and safety when changing from a carbon fiber prosthetic foot to a bionic prosthetic foot. Presented at Orthopadie&Reha-Technik Congress, Leipzig, May 2012.
contents
PRINCIPAL INVESTIGATOR
DEPARTMENTS
Brittany Pousett, BSc, MSc, CP(C)....................................................................... 40
Views From AOPA Leadership..........5 AOPA Board member Elizabeth Ginzel, MHA, CHC, CPO, discusses O&P as part of the health-care team
Meet a Canadian clinician who also spends part of her workday carrying out research responsibilities—studying outcome measures, measuring the effects of pregnancy on prosthetic use, developing upper-extremity control strategies, and more.
AOPA Contacts.......................................... 6 How to reach staff
Numbers......................................................... 8 At-a-glance statistics and data
Happenings............................................... 10
COLUMNS
Research, updates, and industry news
Reimbursement Page..........................18
An Unwanted Spotlight Billing for O&P services in the inpatient setting
CE Opportunity to earn up to two CE credits by taking the online quiz.
CREDITS
Member Spotlight.................................46 n
n
Alchemy Orthotics & Prosthetics Pro-Tech Orthopedics
P.10 People & Places........................................16 Transitions in the profession
AOPA News.............................................. 50 P.18
AOPA meetings, announcements, member benefits, and more
Welcome New Members...................52 Careers.........................................................54 Professional opportunities
Ad Index...................................................... 55
P.46
Marketplace..............................................56 Calendar......................................................58 Upcoming meetings and events
Ask AOPA.................................................. 60 P.48
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FEBRUARY 2019 | O&P ALMANAC
RAC audits, coding for bilateral items, and more
VIEWS FROM AOPA LEADERSHIP
Specialists in delivering superior treatments and outcomes to patients with limb loss and limb impairment.
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 Wise WillowWood, Mount Sterling, OH
The Changing Face of O&P
D
URING THE AOPA LEADERSHIP
Leadership
O&P Conference in Scottsdale, Arizona, in January, a clear message was presented: the need to change. If we are to be sucConference cessful in leading the charge to change, we must be willing to accept and adopt a culture of change. Further, we must reflect upon the past to understand where we came from and where we are now. Change can be exciting, but it is more often met with resistance that can stem from fear of the unknown. The profession has been discussing the need for change for decades with hot topics—from divorcing durable medical equipment (DME) to billing current procedural terminology (CPT) codes. We are a pragmatic and routine profession with a very colorful and unique past—a past that should be remembered and celebrated for what it was and for the foundation it has laid for the future. O&P has changed in practically all aspects: the elevation in education, the size and shape of practices, and the ever-evolving reimbursement challenges, to name a few. With the elevation of educational requirements to a master’s level, we have made significant strides to correlate more closely with other healthcare professions. In addition, the overall demographics, particularly gender, have become more diverse. What else is required to continue to elevate our status as a key member of the health-care team and objectively justify the value of our unique skill sets? As health care continues to evolve, we must determine where we fit within the health-care spectrum. On a small scale, the clinician must be able to demonstrate an improvement or positive change for the individual receiving care. We must objectively demonstrate this change to the healthcare system and—perhaps most challenging—the payor source, both government and private. How do we show that our intervention assisted in a healthy change in the individuals we treat? We start by collecting outcomes, and not just any outcomes. We must focus on functional outcomes. How do we objectively show our intervention positively impacts the life and health of our patients? Our partners in physical therapy have been successful in the collection and utilization of data to show a functional change in their patients. Collaborating with physical therapists, other health-care providers, and organizations is vital. In order to be successful, we need to become a member of the health-care team and integrate into the health-care system. While we have made significant strides in elevating our profession, we must align with like-minded organizations and health-care providers to be part of an integrated system of care. As a collaborative partner in the health-care system, we will be able to demonstrate value, that our intervention plays a key role in improving the life, function, and overall health of the individual. If we are able to achieve these goals, the profession will remain viable and sustainable. Elizabeth Ginzel, MHA, CHC, CPO, is a member of AOPA’s Board of Directors.
O&P ALMANAC | FEBRUARY 2019
5
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.
Printing Sheridan
EXECUTIVE OFFICES
REIMBURSEMENT SERVICES
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.
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
ADDRESS CHANGES POSTMASTER: Send address changes to: O&P Almanac, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314.
Devon Bernard, assistant director of coding and reimbursement services, education, and programming, 571/431-0854, dbernard@AOPAnet.org
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.
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.
Tina Carlson, CMP, chief operating officer, 571/431-0808, tcarlson@AOPAnet.org MEMBERSHIP & MEETINGS Kelly O’Neill, CEM, manager of membership and meetings, 571/431-0852, kelly.oneill@AOPAnet.org Betty Leppin, manager of member services and operations, 571/431-0810, bleppin@AOPAnet.org Yelena Mazur, communications specialist, 571/431-0835, ymazur@AOPAnet.org Ryan Gleeson, CMP, assistant manager of meetings, 571/431-0836, rgleeson@AOPAnet.org Kristen Bean, membership and meetings coordinator, 571/431-0876, kbean@AOPAnet.org AOPA Bookstore: 571/431-0876
SPECIAL PROJECTS Ashlie White, MA, director of strategic alliances, 571/431-0812, awhite@AOPAnet.org O&P ALMANAC Eve Lee, MBA, CAE, executive director, 571/431-0807, elee@AOPAnet.org 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
Reimbursement/Coding: 571/431-0833, www.LCodeSearch.com
6
Design & Production Marinoff Design LLC
FEBRUARY 2019 | O&P ALMANAC
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!
NUMBERS
Business Trends How does your facility compare to the “average” O&P company?
FACILITY SIZE
What does the “typical” O&P facility look like? AOPA’s “2018 Operating Performance Report,” based on 2017 data, captured the financial facts from 90 companies representing 1,022 full-time facilities and 191 part-time facilities. The report offers insights into average facility size, scheduling practices, central fabrication trends, and more.
2,975 Median square footage per facility.
AFTER-HOURS CARE
$
$363 Average sales per facility square foot.
Percentage of Sales By Primary Paying Agents
Hospitals/nursing homes
12 Percent
2 Percent
Percentage of facilities that offer scheduled evening business hours.
Percentage of facilities that offer scheduled Saturday business hours.
76 Percent Percentage of facilities that offer a 24/7 on-call service.
Percentage of facilities that offer home/ mobile visits.
12 Percent Percentage of facilities that provide telemedicine services.
USE OF CENTRAL FABRICATION (C-FAB)
8
81 Percent
38 Percent
Percentage of facilities that outsource to c-fab in some way.
Percentage of customfabricated work produced that was outsourced to a c-fab.
FEBRUARY 2019 | O&P ALMANAC
Medicare (traditional)
24.4% 7.8%
Medicaid (traditional) Medicare replacement
7.2%
Medicaid replacement
7.2%
Contracted private insurance
OFF-SITE CARE
8 Percent
7.0%
Noncontracted private insurance Workers’ compensation
29.6% 2.4% 4.3%
Veterans’ Administration
6.9%
Vocational rehabilitation 0.6% Self-pay
2.1%
Other 0.7% NOTE: Due to rounding, numbers may not add to 100 percent.
Editor’s Note: AOPA’s “2018 Operating Performance Report” is now available through the AOPA bookstore. Visit www.aopanet.org.
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Happenings
RESEARCH ROUNDUP
Researchers Develop Intelligent System for Tuning Powered Knees with a randomly selected set of parameters,” said Helen Huang, PhD, professor in the Joint Department of Biomedical Engineering at NC State and UNC. “We then have the patient begin walking, under controlled circumstances. “Data on the device and the patient’s gait are collected via a suite of sensors in the device,” Huang explained. “A computer model adapts parameters on the device and compares the patient’s gait to the profile of a normal walking gait in real time. The model can tell which parameter settings improve performance and which settings impair performance. Using reinforcement learning, the computational model can quickly identify the set of parameters that allows the patient to walk normally. Existing approaches, relying on trained clinicians, can take half a day.” Details of the study were published in January in IEEE Transactions on Cybernetics.
PHOTO: Helen Huang, PhD
Researchers from North Carolina State University (NC State), the University of North Carolina (UNC), and Arizona State University have developed an intelligent system that relies on reinforcement learning to tune robotic prostheses. The system is designed to reduce the amount of time needed to modify a prosthesis so the user can walk comfortably with a powered knee. The research team demonstrated the feasibility of an approximate dynamic programming (ADP) approach to automatically tune 12 robotic knee prosthesis parameters to meet prosthesis users’ needs. They tested the ADP-tuner on two subjects—one able-bodied and one amputee subject— while walking at a fixed speed on a treadmill. The ADP-tuner “learned” to reach target gait kinematics in an average of 300 gait cycles, or 10 minutes of walking, according to the researchers. “We begin by giving a patient a powered prosthetic knee
Zebrafish Provide New Insights on Scoliosis Treatment
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FEBRUARY 2019 | O&P ALMANAC
response associated with scoliosis. The team concluded that neuroinflammatory signals, which trigger inflammation in the spinal cord, drive spinal curve formation in zebrafish. Ciruna’s team also found that suppressing these signals with common drugs, such as N-acetyl cysteine (NAC), a supplement with both antioxidant and anti-inflammatory activities, blocked the formation of spinal curves or reduced the severity of scoliosis after onset. “Traditionally, scoliosis has been considered to be a disease affecting bone, cartilage, or neuromuscular activities. We were surprised to find an immune response associated with idiopathic scoliosis,” said Ciruna. “Our study has revealed that simple and safe immunomodulating therapies like NAC may be effective in managing scoliosis. … If our findings translate to humans, this could have a profound impact on the treatment of idiopathic scoliosis.” A summary of the study was published in the Dec. 12, 2018, issue of Science Advances.
PHOTO: Jenica Van Gennip
Researchers at The Hospital for Sick Children, affiliated with the University of Toronto (UT), have been studying zebrafish models to determine the biological cause of idiopathic scoliosis. Led by Brian Ciruna, PhD, a professor Skeletal stains of mutant zebrafish, which develop in the Department of Molecular idiopathic-like scolosis. Left: Genetics at UT, the research team Untreated (control) fish develop severe spinal curvatures. Right: has discovered an immune response Siblings treated with N-acetyl cysteine for 20 days after associated with the development of scoliosis onset demonstrate idiopathic scoliosis in zebrafish. significant reduction in spinal curve severity. The research team looked for genes and genetic pathways that were abnormally expressed upon the development of spinal curvature and discovered that immune cells associated with inflammation accumulated at the site of spinal curvature. The researchers believe this discovery indicates a strong immune
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HAPPENINGS
PROCEDURE PRICING
New CMS Rule Requires Hospital Pricing Transparency U.S. hospitals are now required to publish standard price lists, or “chargemasters,” for thousands of types of procedures, tests, pharmaceutical drugs, and medical supplies to comply with a CMS rule that took effect Jan. 1, 2019. The rule requires hospitals to make standard prices public in a searchable online format, to be updated annually. The price lists being published include the full standard charge by each hospital, but they do not reflect out-of-pocket patient costs, the average cost of individual procedures or items, or negotiated discounts and fee schedules with government or third-party insurers. Hospitals may post the price lists in their own formats, which critics say may make it difficult to draw quick conclusions and comparisons—even though doing so is a stated goal of the price transparency rule. “We are just beginning on price transparency,” said Seema Verma, CMS administrator. “We know that hospitals have this information, and we’re asking them to post what they have online.”
RESEARCH ROUNDUP
Scientists Make Progress in Gene Editing for DMD Researchers at the University of Missouri School of Medicine, in conjunction with the National Center for Advancing Translational Sciences and Duke University, have identified and overcome a barrier associated with the gene editing technique known as CRISPR, an approach inspired by the body’s natural defensive ability to fend off viruses. While the tool has not yet been used to effectively treat long-term, chronic conditions, some researchers believe CRISPR gene editing may lay the foundation for sustained treatments of a variety of genetic diseases and conditions. The University of Missouri-led research team is studying how to harness CRISPR to treat Duchenne muscular dystrophy (DMD). Patients with DMD, which primarily affects boys, experience damaged muscle tissue that is replaced with fibrous, fatty, or bony tissue and eventually lose function. DMD patients have a gene mutation that disrupts the production of the protein dystrophin. Absence of dystrophin starts a chain reaction that eventually leads to muscle cell degeneration, as well as loss of ambulation and breathing. Many DMD patients require orthotic intervention as well as wheelchairs.
For this study, researchers treated mice with DMD intravenously using CRISPR and, after testing several strategies, found that treatment could significantly increase dystrophin restoration in both heart and skeletal muscle and reduce muscle scarring. Muscle function and cardiac function also were improved in the mice. “CRISPR essentially cuts out the mutation and stitches the gene back together,” said Dongsheng Duan, PhD, a professor in the Department of Molecular Microbiology and Immunology at the School of Medicine. “In order to do this, the ‘molecular scissors’ in CRISPR, known as Cas9, must know where to cut. The location to cut is flagged by a molecule called gRNA. We were surprised to find that by increasing the quantity of flags, we could extend the effectiveness of the therapy from three months to 18 months in our mouse model.” Duan’s team will continue to test and refine the approach in a mouse model before exploring other models. They hope their research will lay the foundation for improved therapies for DMD and other conditions using CRISPR gene editing.
MEDICARE MATTERS
CMS Releases 2019 Medicare DMEPOS Fee Schedule CMS has released the 2019 Medicare durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) fee schedule, which is in effect for Medicare claims with a date of service on or after Jan. 1, 2019. The new fee schedule for orthotic and prosthetic services will be increased by 2.3 percent over 2018 rates. The 2.3 percent increase is a net reflection of the 2.9 percent increase 12
FEBRUARY 2019 | O&P ALMANAC
in the Consumer Pricing Index for Urban Areas (CPI-U) from June 2017 through June 2018, combined with the annual Multi-Factor Productivity Adjustment (MFP) of -0.6 percent. The 2.3 percent increase represents a 1.2 percent larger amount than the 2018 increase of 1.1 percent. However, the 2 percent sequestration-based reduction to all Medicare payments remains in effect—meaning that
Medicare fee-for-service payments will continue to be reduced by 2 percent due to sequestration. While sequestration continues to impact Medicare reimbursement, it is not cumulative. Providers will continue to receive 2.3 percent more for a service provided in 2019 than they did in 2018 since the 2 percent sequestration reduction would be applied to both claims.
HAPPENINGS
AUDIT ANSWERS
Performant Releases New RAC Audit Performant Recovery, the recovery audit contract (RAC) contractor, Region 5, is initiating a postpayment automated review based on reasonable useful lifetime (RUL) for select spinal orthoses. The spinal orthoses included in the audit are described by codes L0627, L0631, L0637, L0642, L0648, and L0650. Performant Recovery added the review to its list of approved issues on Jan. 1, 2019. The RAC audit for RUL and spinal orthoses is the fourth O&P-specific approved issue since the award of the new RAC contract to Performant Recovery.
FAST FACT
Meat Plant Workers at Risk for Amputation Amputations happen, on average, twice a week at U.S. meat plants. During a recent 31-month period, there were
270 incidents.
Most incidents involved the amputation of fingers or fingertips, but there also were reports of lost hands, arms, and toes. SOURCE: Data compiled by the Occupational Safety and Health Administration and reported by The Guardian, July 2018.
14
FEBRUARY 2019 | O&P ALMANAC
AUDIT ANSWERS
Jurisdictions A and D Release Quarterly TPE Results Noridian, the durable medical equipment Medicare administrative contractor (DME MAC) for Jurisdiction A and Jurisdiction D, has published the quarterly results of its Target, Probe, and Educate (TPE) audits. The audits for both jurisdictions are based on claims audited or reviewed in their respective areas between July and September of 2018.
Jurisdiction A
The results for Jurisdiction A are as follows: • Ankle-foot orthoses (AFOs)/ knee-ankle-foot orthoses (KAFOs)— codes L1970, L4360, and L4361—had an overall claim potential improper payment rate of 39 percent. • Knee orthoses (KOs)—codes L1832, L1833, L1843, and L1851—had an overall claim potential improper payment rate of 79 percent. • Spinal orthoses—codes L0648 and L0650—had an overall claim potential improper payment rate of 25 percent. • Diabetic shoes—code A5500—had an overall claim potential improper payment rate of 4 percent. Some of the common denial reasons for the TPE results include the following: • Documentation does not support basic coverage criteria. • Documentation was not received in response to the additional documentation request (ADR) letter. • The claim is the same or similar to another claim on file. • Documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. • Documentation does not support the need of a custom-fitted item. • Improper advanced beneficiary notice was issued.
Jurisdiction D
For Jurisdiction D, the results of the July through September 2018 quarterly TPE audit are as follows: • AFOs/KAFOs—codes L4360, L4361, L4386, and L4387—had an overall claim potential improper payment rate of 34 percent. This is the same overall claim potential improper payment rate as the last quarter’s results. • KOs—codes L1810, L1812, L1830, L1832, L1833, L1843, L1845, and L1852—had an overall claim potential improper payment rate of 61 percent. This is an increase from last quarter’s overall claim potential improper payment rate of 57 percent. • Spinal orthoses—codes L0625, L0626, L0627, L0630, L0631, L0637, L0641, L0642, L0643, L0648, and L0650—had an overall claim potential improper payment rate of 51 percent. This is the same overall claim potential improper payment rate as the last quarter’s results. • Diabetic shoes—code A5500—had an overall claim potential improper payment rate of 36 percent. The top and common denial reasons for all Jurisdiction D TPE results include the following: • Documentation does not support basic coverage criteria. • Documentation was not received in response to ADR letter. • The claim is the same or similar to another claim on file. • Documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident.
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PEOPLE & PLACES PROFESSIONALS ANNOUNCEMENTS AND TRANSITIONS
Chris Doerger, PT, CP, has been named the director of education for OPAF & The First Clinics. Doerger helped create and implement the OPAF First Clinics, which now offer continuing education credits Chris Doerger, to members of the allied health-care PT, CP rehabilitation team. “I’m excited to help OPAF strengthen and grow its education reach and to continue to fulfill the OPAF missions,” said Doerger. Darren Smith has joined Allard USA as the Northwest district manager. Smith, who holds a doctor of chiropractic degree from the University of Western States in Portland, Oregon, has practiced in Oregon and Darren Smith Washington since 1998. For the past three years, he has taught sports medicine to master’s level students. Smith has been a long-standing member of Allard’s TeamUp. In his new role, he will serve the O&P community in Washington, Oregon, Idaho, Wyoming, Montana, and Northern California.
THE LIGHTER SIDE
BUSINESSES ANNOUNCEMENTS AND TRANSITIONS
AOPA has announced it is has doubled its support of OPAF & The First Clinics. “AOPA is honored and excited to be a Gold Level Sponsor of OPAF in 2019,” said AOPA President Jim Weber, MBA. “Not only does OPAF provide a great service to the O&P community, but it is an exemplary organization in providing positive measures to teach and inform caregivers and professionals to improve the lives of those with physical and mobility challenges.” “OPAF is an organization that keeps on giving and informing the public. AOPA is proud to be a Gold Level Sponsor as we stand in full support of their mission,” added AOPA Executive Director Eve Lee, MBA, CAE. “Their First Clinics inspire and ready those with mobility challenges to remain active in their daily lives.”
AOPA Supplier Plus Partners Thank You to Our AOPA Supplier Plus Partners
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FEBRUARY 2019 | O&P ALMANAC
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REIMBURSEMENT PAGE
By JOSEPH MCTERNAN
An Unwanted Spotlight
E! QU IZ M EARN
New OIG report is a reminder to bill properly for O&P services in the inpatient setting
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 21 to take the Reimbursement Page quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.
CE
CREDITS
18
FEBRUARY 2019 | O&P ALMANAC
I
F YOU ENGAGE IN conversation during an O&P industry meeting, it usually does not take long for the discussion to turn to billing for O&P services in the inpatient setting. While the rules are different based on the type of facility (acute hospital, skilled nursing facility, rehab hospital, etc.), there are always rules. In most instances, the ability to bill Medicare Part B for O&P services delivered in an inpatient setting are quite restrictive, with very limited exceptions to the general rule that inpatient facilities remain responsible to provide all medically necessary services to their patients, either through their own resources or through arrangements with individual providers. Discussions usually gravitate to the exceptions rather than the rule. While these discussions can be healthy, they also can lead to a slippery slope of noncompliance, which can cause significant problems for businesses in the long run. Just because a claim gets paid, it does not mean that it should have been paid—or that it will not be recouped in the not-so-immediate future. This unfortunate reality was recently brought to the forefront through the publication of a report in November 2018 by the U.S. Department of Health and Human Services Office of Inspector General (OIG) titled, “Medicare Improperly Paid Suppliers for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Provided to Beneficiaries During Inpatient Stays.” The report, which covered the three-year period from Jan. 1, 2015, until Dec. 31, 2017, identified $34 million in improper Medicare Part B payments for
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BUSINESS CE
CREDITS P.21
DMEPOS services delivered to Medicare beneficiaries during a Medicare Part A covered stay. While $34 million represents a significant number of improper payments, according to the report, $14.6 million—or 43 percent—of the identified improper payments involved claims for artificial limbs and braces. Said another way, almost half of the improper payments identified in the report were the result of the improper billing of traditional O&P devices delivered in the inpatient setting. This is not good news for our profession and indicates that significant confusion remains regarding when it is and, more importantly, when it is not appropriate to bill Medicare Part B for O&P services that are delivered during a Medicare Part A covered stay. Let’s review the most common scenarios where it is acceptable and appropriate to bill Medicare Part B for O&P services delivered during a Medicare Part A covered stay.
The Two-Day Rule
One exception to the general rule for billing the hospital or skilled nursing facility (SNF) directly for O&P services is called the “two-day rule.” The two-day rule states that a supplier may deliver a completed O&P device to a Medicare beneficiary during a Part A hospital or SNF stay within 48 hours (two days) of the patient’s anticipated discharge. As long as the device is not medically necessary during the remainder of the inpatient stay, and the patient is being discharged to a location that qualifies as his or her home, the supplier may bill the durable medical equipment Medicare administrative contractor
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(DME MAC) directly for the device. However, the supplier must only be delivering the item for the purpose of providing basic instruction on how to use and care for the device. The intent of the two-day rule is not to circumvent the responsibility of the hospital or SNF to provide its patients with medically necessary services. If an O&P device is needed as part of the patient’s recovery or rehabilitation in the facility, it must be provided, or paid for, by the facility regardless of when it was delivered. O&P providers must be especially aware of this requirement as many inpatient facilities try to utilize the two-day rule to avoid having to pay for medically necessary items provided to patients who are under their care. If you deliver an O&P device to a patient during a Medicare Part A hospital or SNF stay and all of the criteria to bill under the two-day rule have been met, the claim may be submitted to the DME MAC following the guidelines below. • Date of service. Under normal billing circumstances, the date of service is usually the date that the completed device is delivered. However, when submitting a claim under the two-day rule, the date of service is the patient’s discharge date from the inpatient facility. Without this exception, the DME MAC would improperly deny the claim as the responsibility of the inpatient facility. While the two-day rule allows you to use the date of discharge as your date of service, the actual date of delivery should be documented in the patient’s chart in case there are questions in the future. • Place of service. Generally, the place of service reported on the claim should correspond with where the item will be used. This holds true under the two-day rule. When billing under this rule, indicate a place of service code of 12 (home).
Exhaustion of SNF Part A Benefits
Medicare limits the number of days for which it will cover Part A SNF services to 100 days per benefit period. A new benefit period begins with a mandatory hospital admission of at least three days 20
FEBRUARY 2019 | O&P ALMANAC
followed by immediate admission to the SNF. As long as a minimum of 60 consecutive days have passed since the patient was last in a Medicare Part A SNF stay, a new benefit period may begin, staring with day 1. If a Medicare patient is in a Medicare Part A SNF stay for less than 100 days and is discharged, he or she remains eligible for the remaining days in the benefit period.
If an O&P device is needed as part of the patient’s recovery or rehabilitation in the facility, it must be provided, or paid for, by the facility regardless of when it was delivered.
that the patient needs. When this is the case, you may submit your claim directly to the DME MAC for consideration. Remember that 100 days is the Medicare Part A benefit limit, and not an entitlement. In order for Medicare Part A to continue covering SNF care, the patient must continue to progress through therapy. Patients must be evaluated on a regular basis by the SNF staff. If the patient fails to progress, Medicare Part A will no longer cover the SNF stay and you may submit your claim to the DME MAC. When determining whether the patient is in a Medicare Part A SNF stay, it is always best to confirm the patient’s status with the facility business office. While therapists and physicians may provide you with limited information, the business office will definitively know the exact Medicare status of any patient at any given time. If you can get this information in writing for inclusion in your files, it may lessen the confusion later regarding who is responsible for payment.
SNF Prosthetic Device Exceptions
For example, if a patient is in the hospital for hip replacement surgery and is discharged to a SNF where he or she stays for 30 days, that patient has 70 days of Medicare Part A coverage remaining for that benefit period. If after two weeks at home, additional SNF care is needed, the patient can be readmitted to the SNF (without an additional hospital stay) and receive another 70 days of Medicare Part A SNF coverage. After 100 days of Medicare Part A SNF coverage within a benefit period, Medicare Part A no longer covers the SNF stay. If the patient remains in the SNF, he or she must pay for room, board, and nursing expenses through personal funds or other insurance. Medicare Part B will cover any orthotic and prosthetic care
As discussed above, SNFs receive a per diem prospective payment system (PPS) payment to provide all medically necessary care for patients in a Medicare covered Part A stay. Beginning in April 2000, however, most prosthetic devices were excluded from the SNF PPS system because the high cost and relatively low volume of prosthetic services provided in SNF settings had resulted in an undue financial burden on SNFs. Excluding most prosthetic devices from the PPS allowed suppliers to bill their DME MAC directly, instead of looking to the SNF for payment. While most prosthetic services have been excluded from the SNF PPS system, certain services, such as prosthetic socks, shrinkers, partial hand and partial feet prostheses, and immediate postsurgical prostheses, continue to be included in the SNF PPS payment. In addition, one prosthetic foot code, L5987, is not included in the PPS exemption list. These items, as well as all orthoses, must be paid for by the SNF when a patient is in a Medicare Part A covered stay.
REIMBURSEMENT PAGE
A list of codes excluded from the SNF PPS can be found at https:// www.cms.gov/Medicare/Billing/ SNFConsolidatedBilling/2019-PartB-MAC-Update.html. Once at this page, scroll down to “Downloads” and select File 1—Part A Stay—Physician Services. (Although the file says “Physician Services,” this list is still applicable to O&P suppliers.) The list of exempt L codes begins about halfway through the file. If a particular L code does not appear on this list, it is not exempt, and you must make payment arrangements with the SNF.
Transferring From Hospital or Home to SNF
Another exception to regular billing rules occurs when a patient is being transferred from a hospital to a SNF. If a custom-fabricated O&P device is ordered for the patient while he or she is still in the hospital, but due to fabrication time, it is not delivered until after he or she arrives at the SNF, the hospital remains responsible for payment of the item. Medical necessity for the custom device was established while the patient
was in the hospital, not in the SNF, so the SNF should not be billed. The two-day rule would not apply in this scenario, either, because the patient is not being discharged to his or her home. Likewise, if the medical necessity for a custom device occurs while the patient is at home, but delivery does not occur until after a Medicare Part A SNF admission, the item may be billed to the DME MAC using the date the medical necessity was established as the date of service and a place of service of 12. Remember that when a hospital or SNF requires the services of an outside supplier for items subject to the Medicare Part A PPS system, it is the facility’s responsibility to make arrangements with the outside supplier. It is always in your best interest to negotiate the terms of your payment prior to delivering your services. While the absence of a contractual agreement does not in any way relieve the facility from its responsibility to pay for such items, making such an agreement prior to providing services will help avoid misunderstandings. The recent report from OIG has cast an unavoidable spotlight on improper
Medicare payments for DMEPOS delivered during a Medicare Part A covered inpatient stay, one that will ensure increased enforcement of the rules that address this situation. Full compliance with Medicare rules and regulations should always be a goal of all O&P providers, but increased scrutiny on inpatient deliveries and billing make the need for compliance that much more important. Failure to understand the rules could result in significant recoupments in the future. Joseph McTernan is director of reimbursement services at AOPA. Reach him at jmcternan@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
PDAC Transition Palmetto GBA takes over as the Pricing, Data Analysis, and Coding contractor
C
MS HAS AWARDED THE Pricing,
Data Analysis, and Coding (PDAC) contract to Palmetto GBA, effective Jan. 15, 2019. Palmetto GBA replaces Noridian Healthcare Solutions, which held the PDAC contract since 2008. Palmetto GBA currently holds the contracts to serve as the National Supplier Clearinghouse contractor and the competitive bidding implementation contractor. In addition, Palmetto GBA served as the contractor for the Statistical Analysis Durable Medical Equipment Regional Carrier, which was renamed the PDAC when the contract was awarded to Noridian in 2008. Doran Edwards, MD, will serve as the PDAC medical director under the new contract. Edwards is currently an associate medical director for CGS, which serves as the Jurisdiction B and Jurisdiction C durable medical equipment Medicare administrative contractor (DME MAC). Palmetto GBA is responsible for performing the following activities as the PDAC contractor: • Support the integrity of the Medicare durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) benefit. • Advise manufacturers and suppliers on the appropriate Health-Care Common Procedure Coding System (HCPCS) codes for billing DMEPOS items. • Receive, evaluate, and process coding verification applications
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for DMEPOS. • Establish, maintain, and update all coding verification decisions on the product classification list housed within the DME MACs. • Establish, maintain, and distribute the National Drug Codes/HCPCS Crosswalk and Oral Anti-Cancer Drugs (OACD) pricing files • Conduct DMEPOS statistical analysis and reporting. The telephone number for the PDAC contractor, 877/735-1326, remains the same after transition to Palmetto GBA. The PDAC website address, www.dmepdac.com, also remains active; however, the site itself may look slightly different. The website will still house the PDAC Product Verification List and instructions regarding how to submit product verification requests. As a reminder, any item described by the following codes requires PDAC coding verification if it is to be billed to Medicare: • A5512 • A5513 • A5514 • A6545 • L0174 • L0450-L0492 • L0625-L0640 • L1845 • L1852 • L1906 • L5969.
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COVER STORY
For What It’s Worth What today’s O&P businesses need to know about buying, selling, and valuating a patient-care company By MICHAEL COLEMAN
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COVER STORY
NEED TO KNOW • Some larger patient-care companies appear to be boosting their purchasing efforts in the O&P market, and experts predict increased activity over the next few years. • M&A activity is picking up in certain areas of the country where small business owners are feeling pressured by a challenging reimbursement environment and heavy competition from larger facilities. But in other areas, small, independent operators continue to thrive. • Companies should examine their financial statements and identify whether revenues can be boosted or expenses decreased. It also may be
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helpful to evaluate the physical condition of the facility and to hire a business manager to focus on improving the facility’s bottom line. • Several factors play a part in determining the company’s actual worth, including recent profit reports, debts, the size of the referral base, and whether the clinical team will continue to work at the company after the sale. • To maximize a company’s price, sell when business is good and contracts and revenues are up, according to experts. O&P facilities should begin planning for a sale several years before retirement.
HEN BRIAN STEINBERG, CO, LO,
prepared to sell his established O&P practice near Chicago a few years ago, he evaluated the balance sheets, assessed the physical condition of the business, considered his staffing situation, and breathed a sigh of relief. The orthotist had long kept a close eye on revenues and expenses, and he carefully cultivated profitable contracts, making his business attractive to buyers. He also had communicated with his clinicians about his intention to sell and assured them their jobs were safe under new ownership. So, in 2016, when Steinberg sold Center for Orthotic and Prosthetic Excellence, operating in northwest Indiana and Chicago, to Comprehensive Prosthetics & Orthotics, to a national O&P company, he got a good price and a new position with the company that came with a greatly reduced stress level. “It’s been a transition, but I think it’s gone well,” Steinberg says. “With today’s tighter fee schedules, if you can expand your scope and your buying power [by folding into a larger company] at reduced cost, you can maximize your profitability.”
Realistic Expectations
Steinberg’s story—that of an independent, experienced O&P practice owner selling an organized, profitable business to a larger collective—is increasingly common in today’s industry. But not all stories about O&P mergers and acquisitions (M&A) have such happy endings. Facility owners who haven’t tended to the business side of their O&P work can be in for a rude awakening when they prepare to sell, say those familiar with the market. Barry Smith, Esq., a lawyer and broker of O&P business sales who claims to hail from the “school of hard knocks,” has sold more than 150 O&P companies and determined the value of 200 more coastto-coast. Smith says he can’t count the times he’s had to tell an eager seller—often aiming for retirement—that his or her O&P business isn’t worth nearly what had been hoped. “I often get calls from someone who says, ‘I’m 65, I’m burnt out, I’m tired, and I want to retire,’” Smith says. “Usually, that guy’s business is not salable. The guy who started it, who has all the referral sources and has all the technical resources, is burned out and wants to leave. So, if you buy that business all you may have bought is a phone number.” O&P ALMANAC | FEBRUARY 2019
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COVER STORY
But Smith says plenty of opportunity exists for owners who are willing to do the hard work involved in making their business more attractive to buyers. “Look at your financial statements and see what’s wrong with them,” he advises. “You may have assets on the books that shouldn’t be there. You may have receivables on the books that are three years old and should be written off. Look at your financial statements and make sure your accountant [reviews] them to make them look as attractive as possible.”
After three years of slow activity on the O&P M&A front, at least in some part owing to uncertainty about changing federal health-care laws and regulations, the climate is starting to rustle to life and the seller’s market is improving, according to Smith. “The last three years—2016, 2017, and 2018— were very, very difficult because there were very few buyers in the market,” Smith says. “There has been relatively little activity compared to the glory days that preceded that. However, 2019 is showing significant signs of life.”
Five Do’s and Don’ts When Selling Your O&P Practice
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DO retain an expert—a lawyer or broker—who can help you determine the value of your practice, navigate the industry’s tricky transaction terrain, and fend off bad advice from well-meaning family and friends.
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DON’T wait too long to sell. The time to maximize your selling price is when business is good and contracts and revenues are up. If possible, begin planning for a sale several years before retirement.
3
DO inform clinicians and other staff members about the looming sale as soon as the decision has been made and put into motion. Hearsay and nervous speculation among employees can damage morale—and your selling price, if staffers jump ship.
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DON’T dither when it comes to closing the sale. Prepare by having your financial records in good order and up to date. As with any transaction, a delay in closure can introduce risks and new variables into the equation and potentially distract operations. You and the buyer should agree upon a closing schedule that includes date-specific steps in the process. DO take a critical look at the aesthetics of your business. Consider replacing shabby carpet or old, banged-up waiting room furniture, or applying a fresh coat of interior paint to the facility, to help boost your “curb appeal” and selling price.
FEBRUARY 2019 | O&P ALMANAC
After some tumultuous times, larger O&P companies, such as Hanger Inc. and Bulow Orthotic & Prosthetic Solutions, have resumed active acquiring activities. He predicts that 2019 will see more M&A activity than in the past couple of years.
Positioning To Sell
Like Smith, Mike Schlesinger believes M&A activity will ramp up this year, in part because some solo practitioners are looking for help in managing the increased workload being placed on them by private insurers as well as Medicare and Medicaid. Schlesinger, who is vice president of corporate business development at Hanger Inc., has shepherded closings on more than 130 O&P practice sales totaling more than $360 million in revenue. “I anticipate O&P companies will continue to explore options to sell in 2019 due to the unique challenges of managing an O&P company, such as regulatory and reimbursement matters,” he says. “M&A activity beyond 2019 will be impacted by changes to health care that may occur or be announced in 2019 to occur in subsequent years.” Schlesinger says that it is extremely important for a prospective seller of an O&P practice to determine exactly why he or she wants to sell, and craft any deal to achieve that end. “A seller’s ‘why’ is critical because if the motivation for selling is not going to be achieved, then the seller should reconsider selling the business,” he says. “Throughout the process—from the initial discussions through the negotiation of final employment and purchase agreement terms—key motivating factors should be reviewed to ensure they will be achieved.” For example, a seller who plans to remain with the business “should ensure the employment agreement allows for vacation desired, flexible working hours, etc.,” he adds. And it’s probably best, in most cases, that the sale isn’t seen as a professional stepping stone. “Selling is a long-term decision, so the idea of selling and then going back into ownership of a practice or flipping a practice would be difficult,” Schlesinger says.
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COVER STORY
“The primary driver for valuation is your profitability. ... If you are very profitable then you’ve got a great chance of getting a great price.” —BARRY SMITH, ESQ.
O&P business owners with “booming” facilities are in the best position to sell, according to Smith. “A lot of people wait until they are ready to retire, and that is normally too late to sell,” he says. “The ideal time to sell is when you’re doing great, year-after-year the business is growing, and you’re making lots of money. Intuitively it seems like the wrong time to sell—but that is the right time to sell to maximize your exit price.” When it comes time to determine what your practice is worth, experts like Smith can help. But he says it’s not terribly difficult to determine. “The primary driver for valuation is your profitability. ... If you are very profitable then you’ve got a great chance of getting a great price.” Steinberg agrees and suggests that hiring a business manager in the run-up to the sale, if there’s not already one in place, can help shore up books and make the business more attractive. “It’s pretty much just improving that bottom line and really showing that you’re profitable,” he says. “You could have a practice and bring in $5 million a year, but if you’re spending $6.5 million it’s not that attractive to buyers. I had a business manager from inception to run the business part of the practice. Sometimes, as clinicians, we think a 28
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little differently than somebody trained in the business side of it.”
Practical Pricing
In 2015, Jeff Erenstone, CPO, president of Mountain Orthotic & Prosthetic Services in Lake Placid, New York, decided to take on a partner because he simply needed the help. In addition to his traditional job, Erenstone was launching Create O&P, a 3-D manufacturing company focused on affordable and accessible prostheses. But all that sideline work—as rewarding as it might have been—was eroding his focus on Mountain O&P Services. Something had to give, so Erenstone approached a favorite clinician about buying into the business. “To be able to have the mental bandwidth to be able to take on these new ventures, I needed someone else in the practice who was taking care of the day-to-day,” Erenstone explains. “We have this individual who joined the practice and over the years worked to prove he deserved to be an owner. We got a valuation and set the price of what he was purchasing so he could buy into the practice.” Erenstone admits that he viewed his business—at least anecdotally or from a gut perspective—as being worth more than it was ultimately
valued by an outside appraiser. But he also learned that discrepancy is a common part of the sales experience for owners. “There is this thing [your business] that you have put all of your heart and soul into, and it’s hard to come up with that number” for a sales price, Erenstone says. “Always, the person who has put their heart and soul into [building the business] will come with a number higher than what the valuation is.” Smith agrees that an O&P practice’s “bottom line drives value,” but he says myriad other elements of the business also come into play: “The other factors are the balance sheet, whether you have debt, and whether you’re staying on” to work at the business—or at least oversee the transition for a period of time,” Smith explains. “A business where the staff is goosey and may be leaving is worth a whole … lot less than one where they are all staying. Are there noncompetes [clauses in the contract] in place, and are they enforceable if they [clinical staff ] leave? That is very important. “Is all their business coming from one referral source or lots of referral sources?” Smith adds. “Are there lots of contracts or very few contracts? Is there a lot of competition or are they alone in the city?” Smith also advises taking a hard look at the actual brick-and-mortar of a business in addition to its bank balances. “Take a very objective third-party, dispassionate look at your business from the outside,” he advises. “Consider the curb appeal. Is the paint peeling off the building? Is the lab a complete mess that hasn’t been touched in 30 years? Are the waiting rooms dirty? A buyer’s going to want to come and do a site visit and walk around. They’ll be thinking, ‘Do I have to come in here and spend $30,000’” in paint and flooring costs or invest in other upgrades to the facility itself?
Geographical Differences
In some areas of the country, larger O&P practices are purchasing smaller companies—a trend Smith expects to continue in the foreseeable future.
COVER STORY
“There is a national issue that affects how O&P owners think,” he explains. “That is, if they stay independent and do their million dollars a year, are they going to be able to compete against the big boys who are going to have statewide or national contracts? “If I’m in a state where most of the contracts go to a player who has 30 offices in the state and I’m not able to do any business in that state, my business is going to become worthless,” Smith continues. “The small independents are very fearful of being left at the station, and the train is leaving.” That concern is warranted in some places, says Smith, and “is driving a lot of people to sell even though they may not be ready to sell because they’re too young or they’re forced to sell to protect themselves. There are global and national forces at work, and that trend is increasing.” However, Smith also emphasizes that this trend is regional in nature. Smaller, independent operators are
often thriving, especially those in areas located far from large cities. “One of the fundamentals that drives the value proposition is geography,” he explains. “Even though there has been a great deal of consolidation, there are still six states that have experienced zero consolidation to date, and in many states, there are pockets where there is no competition within 100 miles. “As a result, once you leave the city center where the population density is greatest, there are ample opportunities for private clinics to excel,” Smith adds. “Consolidation activity follows the population, so if you look at a map of the United States you can predict, with amazing accuracy, where the competition is greatest. Competition tends to lead to competitive pricing, and that often looks like a race to the bottom. Thus, the entrepreneur who is not in the heart of the city may find margins better than some of his peers.”
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For those companies that are considering selling and are seeking optimal terms, Smith emphasizes the importance of retaining professionals with experience in O&P practice sales. Schlesinger also recommends hiring professionals, in part to keep transactions on track. “Prepare by having your financial records in good order and up to date, and have resources ready to support, such as your attorney and tax accountant,” he says. “As with any transaction, a delay in closure can introduce risks and new variables into the equation and potentially distract operations,” he adds. “The buyer should prepare a closing schedule that is agreed upon with the seller, outlining key steps in the process with the due date for the completion of each step. This schedule will assist in mitigating delays in the process and closing the transaction on schedule.” Michael Coleman is a contributing writer to O&P Almanac.
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By CHRISTINE UMBRELL
Building Value,
BOOSTING PROFITS O&P pros discuss alternative revenue streams that enhance profits and position facilities as comprehensive solutions providers
NEED TO KNOW Some O&P facilities are taking advantage of opportunities to broaden their scope of practice by exploring alternative revenue streams in an effort to boost profits and gain greater brand recognition. Many companies offer rehabilitationrelated items, such as canes and walkers, compression socks, and mastectomy products, most of which are cash-based. While some of these items do not have significant profit margins, facilities with these offerings become one-stop shops for patients. Some facilities identify areas where they excel and expand their practice to offer specialized products. Such is the case for Blue Sky Orthotic and Prosthetics, which does a significant business in competitive sports solutions and adaptive prostheses. Another option involves employing nontraditional O&P staff. The University
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FEBRUARY 2019 | O&P ALMANAC
of California—San Francisco O&P Centers, for example, has hired athletic trainers as off-the-shelf fitters, resulting in increased efficiency and greater patient volume. Employing certified pedorthists can position facilities as more comprehensive solutions centers, which could boost income. Offering foot orthoses and custom-molded shoes and marketing them to athletes, teachers, and nurses could lead to more cash-based sales. Other facilities have built central fabrication facilities that market their services outside of their own clinics. Whatever type of ancillary service a facility decides to explore, each one carries with it potential risks and rewards. It’s important to maintain focus on a facility’s core O&P business while pursuing additional avenues to grow the company and build a brand.
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#1
Become a One-Stop Shop
Patients who visit TCOP can purchase a variety of nontraditional O&P items that could be useful in the rehabilitation process. At any given time, the facility has for sale compression socks, shoes and inserts, canes, crutches, and walkers, many of which are noncovered items and must be paid
PHOTO: Blue Sky Orthotic & Prosthetics
S O&P COMPANIES FACE increasing administrative challenges and decreasing reimbursements, some companies are turning to alternative revenue streams. “Our industry is feeling the pressure from multiple avenues,” including increasing documentation requirements and numerous audits—RAC audits; CERT audits; and the Target, Probe, Educate program—which tie up staff and take clinicians away from revenue-producing patient-care activities, explains Bob Tillges, CPO, FAAOP, president of Tillges Certified Orthotic Prosthetic Inc. (TCOP) in Minnesota. With higher administrative and operational costs, “ancillary services, coupled with ‘leaning out’ your dayto-day operations, are going to be the key to set you apart as a profit leader,” Bob Tillges, CPO, FAAOP he says. While it continues to be important to ensure that O&P facilities’ internal processes and core business remain efficient, exploring alternative revenue streams could lead to increased profits, greater brand recognition, and more referrals. When it comes to deciding which ancillary services to provide, there are many to explore—from stocking noncovered rehabilitation and mastectomy products to fitting specialized sports prostheses to staffing athletic trainers to opening central fabrication facilities, and beyond. Which make the most sense for your business? Owners and clinicians share six suggestions and rationale for offering value-added services and products.
Blue Sky clinicians have worked with competitive runner James Ortiz to fit him with running prostheses. for in cash. “Cash basis sales provide an opportunity for practices to collect on alternative revenues,” says Tillges. “This could be captured … by offering a second pair of shoes during fittings, mastectomy-based products, or any other ancillary supplies that tie into a patient appointment.” While it can be difficult to make a profit from providing some of these cash-based items, TCOP has created efficienMike Tillges, CPO cies by offering high volumes, and thus negotiating better pricing from suppliers—and the benefits come in being able to provide more comprehensive care. “We become a one-stop shop in providing a high volume of these services, so we get lots of referrals from different physician groups,” says Mike Tillges, CPO, co-vice president of TCOP. “But for that to work, you need to start with a well-operating, efficient facility—and then use these ‘extra’ products as a branding tool.” Mastectomy services, in particular, can provide some extra revenue, according to Dennis Clark, CPO,
chief leadership officer at VGM Group and presDennis ident of Clark Clark, and Associates CPO Prosthetics and Orthotics. “There’s a big push to get custom mastectomy products covered by private payors and Medicare,” says Clark. “But right now, it’s the only type of prosthesis that is not covered” and remains a cash business. “There’s a limited clientele, but it can be a very nice additional revenue stream,” he says.
#2
Specialize in Sports Prosthetics
Some facilities find success by identifying areas in which they excel and expanding their practice to offer specialized products and services. Such is the case for Aaron Foreman, MSPT, CPO, owner of Blue Sky Orthotic and Prosthetics in Austin. Foreman is a former competitive cyclist who works with and employs other athlete/prosthetists at Blue Sky. Their knowledge and expertise in competitive sports form the basis for value-added sports prosthetics solutions. O&P ALMANAC | FEBRUARY 2019
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PHOTO: Blue Sky Orthotic & Prosthetics
Aaron Foreman, MSPT, CPO, modifies a mountain bike test socket. Clinicians at Blue Sky Orthotic and Prosthetics created a specialized mountain bike arm for a patient.
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revenue stream for the right O&P clinic that has interest in adaptive sports,” says Foreman.
#3
Hire Athletic Trainers
Another option some facilities are trialing involves employing nontraditional O&P staff. “We started hiring athletic trainers eight years ago to function as off-theshelf (OTS) fitters” at the University
Former Wimbledon champion and tennis coach Dennis Ralston is a frequent patient at Blue Sky.
PHOTO: Blue Sky Orthotic & Prosthetics
“We work with many adaptive athletes who need sports prostheses for cycling, mountain biking, and motocross, along with other sports like weight lifting, running, and rowing,” says Foreman. Because Blue Sky offers targeted athletic solutions, patients with specialized needs for adaptive prostheses are drawn to the facility, and its reputation has grown via word-of-mouth. These specialized offerings go above and beyond patients’ base prostheses, so they are typically cash-only offerings—leading Aaron Foreman, to more timely MSPT, CPO reimbursement and a profitable segment of the business. In addition, Blue Sky works closely with the Challenged Athletes Foundation, Ottobock, Össur, and TRS Boulder to get the optimum components for the athletes. Blue Sky also sponsors many adaptive athletes and assists them in preparing for big events like the Paralympic Games, Endeavor Games, and other sporting events. “These affiliations can help boost marketing efforts and offer a good alternative
of California—San Francisco (UCSF) O&P Centers, says Matthew Garibaldi, MS, CPO, director at UCSF O&P Centers and associate clinical professor in the UCSF Department of Orthopaedic Surgery. In many ways, the master’s degree earned by athletic trainers “parallels that of an MSOP student, with regard to their understanding of anatomy and physiology, so their incorporation into our practice was an intuitive decision,” explains Garibaldi. “Our athletic trainers are required to sit for their CFo certificate, so they’re fully credentialed to treat OTS cases
PHOTO: University of California—San Francisco O&P Centers
without supervision,” he says. “This boosts efficiency by allowing our COs to focus on the more time-consuming, complex, custom Matthew Garibaldi, cases.” The net MS, CPO result is increased patient volume, which ultimately improves the hospital’s bottom line. Garibaldi says that some athletic trainers are attracted to O&P work due to the regularity of office hours. A typical athletic trainer setting, such as a high school or college, requires trainers to work odd hours and weekends, which leads to high burnout rates among this population, he says. “Also, an athletic trainer will typically receive better health care and retirement benefits as an athletic trainer with a CFo certificate.” Additionally, given that athletic trainers don’t require standard O&P tooling or machinery to fit OTS braces, they aren’t “tethered” to the traditional O&P office. “As such, they’re free to treat patients in community, across a variety of healthcare settings,” Garibaldi explains. “This improves access to care for UCSF O&P Centers’ patients in outlying regions and helps broadens our facility’s market area.”
Hiring athletic trainers who earn their CFo certificates has boosted efficiency at UCSF O&P Centers.
While laws and regulations may vary from state to state, California is attempting to pass legislation that would allow licensure for athletic trainers and a possible avenue for them to bill for services. “Once this legislation passes, we’ll add a new revenue stream to our department by providing postamputation prosthetic training services,” Garibaldi says. “We’ve already created an Amputee Comprehensive Training Program that incorporates athletic training services in anticipation of this legislative change.”
PHOTO: University of California—San Francisco O&P Centers
An athletic trainer works with a patient at the University of California—San Francisco (UCSF) O&P Centers.
#4
Employ CPeds—For More Than Diabetic Shoes
Some O&P companies have shied away from hiring pedorthists and offering therapeutic shoes and foot orthoses due to profit margin concerns. But O&P owners should reconsider this option as a potentially lucrative alternative revenue stream, says Robert Sobel, CPed, past presRobert Sobel, ident of the Pediatric CPed Footcare Association. “The biggest mistake many O&P facilities make is automatically thinking about the Therapeutic Shoe Bill when they hear the word ‘pedorthics,’” says Sobel. He agrees that offering diabetic shoes for Medicare patients is not very profitable—“but there’s so much more to pedorthics.” Providing foot orthoses for athletes, teachers, nurses, and others who spend a lot of time on their feet offers “significantly greater profit margins than what Medicare will pay you for diabetic shoes,” explains Sobel—and many patients pay out-of-pocket. In addition, shoe modifications—such as buildups or rocker soles—and custommolded shoes are both markets that are underutilized, according to Sobel. O&P ALMANAC | FEBRUARY 2019
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“Medicare and Medicaid do not pay much [for shoes], but there’s a big market in self-pay—for example, for patients with Charcot-Marie-Tooth disease or rheumatoid arthritis.” Facilities that have floor space to showcase footwear samples can draw in business, Sobel suggests. “Nurses and teachers are repeat customers. Insurance is backing away [from covering this type of footwear], so it’s become largely self-pay. If you can offer space to show a wide selection,” these customers are likely to buy extra pairs in different colors and styles, and recommend your services to their co-workers, he says. And self-pay means immediate reimbursement, without “chasing your money from insurance companies.” Sobel acknowledges that most O&P companies are used to providing devices with “higher ticket prices” than pedorthic offerings. “But if you
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look at the margins, and the costs of staff time in billing and appeals” for orthotics and prosthetics, then the extra income from adding pedorthics may be enticing. He encourages O&P facilities to study their markets to determine what types of pedorthic patients they might be able to serve, then hire a certified pedorthist and develop a strategic marketing campaign to achieve an optimal return on investment.
#5
Build a C-Fab
Some O&P facilities have added to their profits by creating their own central fabrication (c-fab) capabilities—and offering services outside of their own clinics. For example, TCOP created Tillges Technologies to fabricate devices for TCOP as well as other local and national facilities that choose to outsource. Of course,
c-fab facilities must comply with accreditation rules from the American Board for Certification in Orthotics, Prosthetics, and Pedorthics, as well as any applicable rules and regulations from the Occupational Safety and Health Administration. “For our practice, becoming a c-fab has been an opportunity for us to diversify into an alternative revenue stream,” says Thomas Tillges, operations process manager of TCOP. As with the company’s patient-care facilities, efficiency is key. “We have standardized our fabrication procedures so that we have a job move through the fabrication facility, rather than have one tech move it along,” he says. “Moving to a more automated process, rather than the traditional mom-and-pop model,” ensures that lean production processes are followed and prices are contained, says Thomas Tillges.
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#6
Transport Patients
Patient transportation services could offer another possibility for expanding revenues, according to Clark. While his facility has not yet tried this option, Clark has spoken with some transportation drivers and has given a lot of thought to how such a service could work at an O&P company. Nonemergency medical transportation services is a growing business—particularly given the number of baby boomers becoming seniors. O&P companies that research the liability, licensing, and insurance issues could ultimately benefit from offering transportation services—and might be able to expand the business beyond just transporting patients backand-forth from the O&P facility. “Some of those same patients could use you for other clinical appointments” or rides to other destinations. “You can have some pull-through,” says Clark. While this service could be positioned as cash only, “this is a billable
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item to insurance companies” for some medical appointments, says Clark. While not billable under the L-code system, a company’s properly structured “transportation division” could charge insurance for billable transports.
Calculate the Risks—and Rewards Whatever type of ancillary service a facility decides to explore, it’s important to remember that each one carries with it costs—not just startup costs, but ongoing costs as well. Pursuing new opportunities usually means increased staffing requirements and higher costs in materials, machinery, and space, says Mike Tillges. But “successful practices are budgeted well and know how to control costs,” he says. One option to counteract some of the costs involved in hiring more staff is to consider hiring temporary employees or consultants, rather than full-time employees, suggests Bob Tillges. “We’ve hired temporary technical staff and administrative staff” to help with expansions, he explains.
“Then, as we improve efficiencies, we can reduce staff” without firing anyone since temporary employees are not permanent staff. Risks are inherent in any business, says Mike Tillges. With ancillary services in particular, “the biggest risk is losing focus on your core and becoming overdiversified—that can be a real strain on any practice.” But companies that are growth-oriented, have a solid managerial team in place, and leverage modern technologies to innovate will be best positioned to profit when expanding facility offerings. “A well-budgeted practice that knows how to control costs and not take on too much at once will succeed,” he says. “Ancillary services,” he adds, “give you an opportunity to grow your company and your revenue, expand your brand, and serve more patients.” Christine Umbrell is a contributing writer and editorial/production associate for O&P Almanac. Reach her at cumbrell@contentcommunicators.com.
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PRINCIPAL INVESTIGATOR
Northern Studies Vancouver’s Brittany Pousett, BSc, MSc, CP(C), researches upper-limb prosthetics, 3-D-printed sockets, outcome measures, and more
Fulfilling AOPA’s mission to advance research in the profession, O&P Almanac introduces individuals who have undertaken O&P-focused research projects. Here, you will get to know colleagues and health-care 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.
C
ANADIAN PROSTHETIST BRITTANY POUSETT, BSC, MSC, CP(C),
enjoys both patient care and data crunching, and she feels fortunate to be able to split her time between clinical and research responsibilities at Barber Prosthetics Clinic in Vancouver. “I spend approximately 20 percent of my time involved in various research initiatives— all of which directly impact the care I can offer to my patients,” she explains. Pousett’s research endeavors run the gamut from directing and completing in-house research projects to acting as
a clinical advisor on projects in collaboration with universities of health institutions. She also supervises student projects—master’s, bachelor’s, and term projects—for O&P, engineering, kinesiology, and industrial design students. “Through this, we have been able to develop expertise on in-clinic research and contribute to the advancement of our profession,” she says. Over the past several years, Pousett has been involved in a wide range of O&P research projects, including studying the benefits of using outcome measures in clinical practice to shape patient engagement, measuring the effects of pregnancy on prosthetic use, developing novel upper-extremity control strategies, exploring 3-D printing, and evaluating rehabilitation programs.
Adopting the O&P Research Mindset
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PHOTOS: Brittany Pousett, BSc, MSc, CP(C)
Brittany Pousett, BSc, MSc, CP(C), traveled with the M.A.S.S. Impact Team to the Cybathlon competition in Zurich, Switzerland, in October 2016.
Pousett made the decision to pursue O&P during her undergraduate years at the University of British Columbia (UBC), when she studied biophysics. She came to realize two things about herself: She loves designing things— particularly devices that interact with humans—and she loves being with people. “Prosthetics seemed like the perfect fit of hands-on design and problem solving with patient care and developing relationships,” she recalls. “I’ve loved this combination from day one.”
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PRINCIPAL INVESTIGATOR
Pousett and her team developed a prototype of the M.A.S.S. technology for upper-extremity prostheses. Upon her UBC graduation, Pousett entered the British Columbia Institute of Technology (BCIT) to study O&P; there, her capstone project became her first O&P research project. “I looked at how torsion adaptors impacted an individual’s ability to complete basic everyday tasks,” Pousett explains. “I always loved research, specifically analyzing data and drawing meaningful conclusions, and prosthetics research was a natural extension from my initial exposure to physics research.”
Since that initial project focusing on torsion, Pousett has branched out to study other areas, mainly relating to prosthetics. In one important study, she developed a novel control strategy for electric upper-extremity prostheses. “In recent years, several multiarticulated hands have become commercially available, allowing for more complex function than the previous generation of hands,” she explains, but the strategies available to control electric hands had remained largely unchanged and are the largest
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PHOTOS: Brittany Pousett, BSc, MSc, CP(C)
Pousett works with Daryl Murphy, RTP, experimenting with a 3-D printer.
barrier to patients using these new hands to their full potential. To address this need, her facility, Barber Prosthetics Clinic, partnered with biomedical engineers and kinesiology researchers from Carlo Menon, PhD’s, MENRVA Research Group at Simon Fraser University in Burnaby, British Columbia. “Our aim was to provide a more natural and intuitive control strategy for upper-limb prostheses with the Muscle Activity Sensor Strip (M.A.S.S.),” she says. Her team completed several studies on this technology and traveled to the Cybathlon competition in Zürich, Switzerland, in October 2016 to showcase the technology. “The main goal of the Cybathlon was to provide a platform for the development of novel assistive technologies that are useful for daily life, and it was incredible to see the wide range of devices featured.” Another area of focus for Pousett has been evaluating the strength, and suitability for clinical practice, of 3-D-printed sockets. “As 3-D printing gains exposure, patients are beginning to ask if 3-D-printing technology is right for them. As prosthetists and technicians, we use several manufacturing methods to provide our patients with safe, reliable treatments,” she explains. “However, currently there is no clinical standard for evaluating the strength of sockets.” Her research aimed to address this issue by examining how 3-D-printed socket strength compares to the strength of sockets made using conventional methods and then studying how different 3-D-printing parameters influenced this strength. Pousett also has engaged in a less rigorous, but still important, study exploring the use of outcome measures in clinical practice, especially how they are used to motivate and engage patients. She describes her activity in this area as “learnings through clinical practice.” She has presented on this topic more than a dozen times— including at the 2018 AOPA National Assembly in Vancouver—and has written related magazine articles.
Serving the O&P Patient Population Improving the quality of life for O&P patients is a pervasive theme throughout Pousett’s work—both in the clinic at Barber and in her research projects. A wide range of patients will benefit from her studies, she says. For example, she is co-author of an upcoming publication that is intended to benefit older adults with prostheses; the study explores “their prosthetic use patterns and how we can alter rehab programs to better address their needs,” she says. And her team’s study of prostheses and pregnancy will ultimately provide prosthetists with better information to inform the care of pregnant women who have transfemoral amputations. In addition, all prosthetic patients will ultimately benefit from her studies into how using outcome measures can increase patients’ engagement in their care.
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Trans-Tibial Waist Belt Trans-Femoral Waist Belt Pousett discusses the results of a Box and Blocks outcome measure test with a patient.
PHOTO: Brittany Pousett, BSc, MSc, CP(C)
Pousett is thankful for several partnerships with universities that have been instrumental to her research. “They allow us to access expertise and manpower than we would never have on our own.” In particular, some of her team’s research is conducted in collaboration with students who choose to do prosthetics-related research projects. “This lets us pilot various ideas and explore if they are worth pursuing further.” She also is appreciative of being employed in a career that she genuinely enjoys. “I find it so rewarding to see first-hand what the research shows and to begin considering how I can use it in practice.”
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PRINCIPAL INVESTIGATOR
Pousett conducts a self-report outcome measure with a patient. Pousett takes pride in her work supervising student projects, some of which are undertaken by the O&P students at BCIT, in helping to develop the researcher side of the future clinicians. Her facility hosts weekly clinical rotations for O&P students, where she demonstrates “an O&P clinical researcher in action.” She also mentors some of the new graduates. Outside of her clinician and research roles, Pousett relishes her role as wife and as mother to her 18-month-old daughter. She takes breaks from her studies to “craft”— sewing, knitting, and needle-pointing—and spends a lot of time outside, engaging in hiking, snowboarding, and canoeing activities. She also is an avid gardener: “I’ve been trying to grow as much of our own produce as possible and love canning/preserving what we grow in our backyard.”
Pousett analyzes a patient's gait during a walk text.
Calling All Researchers
Looking to the future, Pousett is hopeful that more O&P professionals will become involved in research. She advises those who are interested in research to “network, network, network”—to “figure out who is doing research that you’re passionate about and see if you can get involved.” Even those more experienced clinicians with less research knowledge can get involved—Pousett encourages this demographic to “consider hiring a younger clinician who has a research background and give them freedom to explore what being a research clinician in your facility looks like.”
She notes that research studies always need help with recruitment. “See if your facility can help recruit for larger studies,” she suggests. As far as her own research plans go, Pousett anticipates that her work with outcome measures and 3-D printing will continue. “We want to provide strong support for the benefits of outcome measure use for our patients and determine if 3-D printing is suitable for clinical use and under what circumstances,” she says. “We also are beginning some collaborating with the UBC Bionics Network to develop some new technology for upper-extremity prostheses.”
Notable Works
• Ferigo D., Merhi L.K., Pousett B., Xiao Z.G., Menon C. “A Case Study of a Force-Myography Controlled Bionic Hand Mitigating Limb Position Effect.” Journal of Bionic Engineering 2017; 14(4): 692-705. • Ahmadizadeh C., Merhi L.K., Pousett B., Sangha S., Menon C. “Toward Intuitive Prosthetic Control: Solving Common Issues Using Force Myography, Surface Electromyography, and Pattern Recognition in a Pilot Case Study.” IEEE Robotics and Automation Magazine 2017; 24(4): 202-111. • Cho E., Chen R., Merhi L.K., Xiao Z.G., Pousett B., Menon C. “Force Myography To Control Robotic Upper-Extremity Prostheses: A Feasibility Study.” Frontiers in Bioengineering and Biotechnology 2016; 4(18): 12.
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PHOTOS: Brittany Pousett, BSc, MSc, CP(C)
Brittany Pousett, BSc, MSc, CP(C), has been involved in the publication of many important articles and papers over the course of her education and career. Three of her most impactful publications relate to her studies of control strategies for upper-limb prostheses:
MEMBER SPOTLIGHT
Alchemy Orthotics & Prosthetics
By DEBORAH CONN
The ‘Fun’ Factor Alaska facility features inviting play areas and a resident pet
T
HE JOURNEY OF WIL SUNDBERG, CPO, as an
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Chris McKillop, a CPOA and lab technician, talks with a group students enrolled in the University of Alaska’s Physical Therapy Assistant Program.
FACILITY: Alchemy Orthotics & Prosthetics OWNER: Wil Sundberg, CPO LOCATION: Anchorage and Fairbanks, Alaska HISTORY: 12 years
McKillop puts the finishing touches on a custom foot orthosis.
Maeve serves as the facility’s “chief fuzziness officer and director of entertainment.”
sense of play and warmth of the facility. Sundberg jokes that he adopted Maeve so that people would think he was talking to her instead of talking to himself as he worked. Patients have come to expect to see Maeve at all of their appointments. “I’ve had people say they would have rescheduled had they known she wasn’t going to be in the office,” Sundberg says. The gait room/playroom, dubbed The Mullet, also provides space for Alchemy’s lab, where Sundberg and his staff build and adjust devices. All fabrication is completed in-house, and patients can watch as technicians work. “Everybody likes watching a leg or a brace get made,” says Sundberg. “It allows them to see the process and be part of the solution.” Alchemy O&P has a fairly large base of pediatric patients, in addition to adults. “Before I started taking a lot of pediatric cases, I thought it would be like treating smaller adults. Not true!” he says. “I also learned a lot about pediatric O&P by having my own children. I realized some of the things I had been asking parents to do—like, ‘Put
Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net.
PHOTOS: Alchemy Orthotics & Prosthetics
O&P practitioner has been both geographic and personal. He grew up in Minnesota and kept moving, working as a certified prosthetist/ orthotist in Idaho, then Montana, and finally Alaska. As he moved westward, Sundberg’s ideas evolved as to what a proper O&P facility should look like. “Once I got over the stage of [worrying about] what the norm is, I quit caring about it and started to have fun,” he explains. The result is Alchemy Orthotics & Prosthetics, with offices in Anchorage and Fairbanks. Launched in 2007 as a one-man shop in a tiny two-room office, Alchemy steadily expanded, powered by happy patients, says Sundberg. “We never really advertised because word-ofmouth was so successful.” Alchemy O&P opened an office in Fairbanks in 2013 and moved its Anchorage facility into a large warehouse space of about 2,900 square feet five years ago. The move was initially made to accommodate a computerized gait system. Sundberg soon realized that much of the 1,700-square-foot gait analysis room wasn’t being used, so he added toys and games, including a pitching machine, Nerf guns, and hockey gear. Whimsical scenes are painted on the walls, and the facility has an underwater ocean room, comic book room, and graffiti throughout. Maeve, the resident dog, is beloved by all and adds to the
on the brace, put them to bed, and make them go to sleep’— were completely unrealistic.” Sundberg is enthusiastic about adopting high-tech methods, including 3-D printing and computer-aided design, but he insists that they complement— not replace—traditional hand skills. By combining tradition and technology, Alchemy O&P can speed the process and improve the product significantly. “We can get a lot more done in one appointment than other facilities can in weeks,” he says. “For example, we are able to fit customized orthotic shoe inserts in an hour and a half.” Because many patients fly in from far-flung areas of the state, fewer appointments and fast turnaround times are especially important. The facility is an integral part of the local community. To celebrate this year’s winter solstice, the Nordic Skiing Association of Anchorage held a tree tour on a cross-country trail. Alchemy O&P won a prize for its figure of a skier built entirely of prosthetic parts, a contribution that highlighted the facility’s expertise and its sense of fun. Sundberg is working to establish a residency program for new clinicians, hoping to instill in them his respect for hand skills as well as the latest technology. Along the way, they are likely to appreciate his quirky approach to serving patients—all while having fun.
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Pro-Tech Orthopedics
By DEBORAH CONN
Support Systems Massachusetts company offers custom orthoses for a wide range of needs
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OM KIMBALL AND MARTIN ANDERSON joined Pro-Tech
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FEBRUARY 2019 | O&P ALMANAC
Frank Kimball, production manager; Tom Kimball, president and owner; and Leo Kazlauskas, general manager
posture, and function. “Available
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feedback, improved musculoskeletal support and alignment, and better quality of movement,” says Kimball. The garment has integrated panels that help support core stability. It can be modified to create thoracic extension or lift for scoliosis, and hip adduction, as well as support for de-rotation and internal rotation. “Because of its design, you can create a combination of stretch and stability to help achieve your goals for the patient,” Kimball says. “You need core stability, which you get from a lumbar/ pelvic reinforcement panel that serves as an anchor for the garment. Then you build on that.” Not every patient is a candidate for the SDO, notes Kimball, who says an orthotist or physical therapist (PT) can determine if a patient reacts sufficiently to proprioceptive feedback. The item is available in 13 versions, including those for upper and lower extremities, as a body suit,
Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net.
PHOTO: Pro-Tech Orthopedics
Orthopedics in 2006, three years after Andrew Carroll, CO, launched the orthopedic manufacturing business in Connecticut. A few years later, Carroll left to return to patient care, and Kimball and Anderson took over the business and moved the company to Massachusetts. Kimball became the sole owner following Anderson’s recent retirement. Pro-Tech manufactures custom head-to-toe orthoses. The company, now located in Raynham, Massachusetts, occupies about 10,000 square feet, encompassing both administrative and manufacturing functions, and has 12 employees. “We have a small group of talented professionals,” explains Kimball, “and we’re always looking for more technicians. They’re hard to find in this industry because most experienced people are already working. So we look for young, talented individuals we can train.” Pro-Tech’s products include orthoses to address a range of diagnoses, including neurological issues, cerebral palsy, scoliosis, and trauma. The company recently introduced an adjustable sternal bar, as well as the Achilles Contracture Management Orthosis, a total-contact removable ambulatory boot with an adjustable angle at the ankle. The company’s flagship product is the Sensory Dynamic Orthosis (SDO), a custom compression garment made of Lycra that increases sensory feedback, helping improve positioning,
and variations that offer short and long legs and sleeves. Pro-Tech is working on securing a specific L code for the garment. “It’s tough when a product evolves,” says Kimball. Nevertheless, he says, if practitioners have evaluation, assessment, and justification documents, they will likely be reimbursed for the device. Kimball believes there is a growing market for scoliosis and lower-extremity orthoses. “Physicians are increasingly using off-the-shelf devices for trauma patients, so we don’t have as much business there as we used to. But scoliosis is such a complicated condition that we have to treat it on a custom level. The same is true for cerebral palsy kids and more complicated diagnoses.” He notes that custom lower-extremity devices are becoming more common as well. “Before, we wouldn’t see anyone send out lower-extremity, only custom spinal,” he says. “But custom offers superior quality in the brace and fit, and we are watching this market grow.” Another growing trend is monitoring usage, he says. “We offer a device called the Orthotimer, an electronic microsensor that documents wearing time. We can integrate it into all kinds of devices, including orthoses, prostheses, insoles, and compression garments.” Kimball is pleased with the steady growth of Pro-Tech Orthopedics—about 10 percent each year—crediting the company’s pricing, service, and quality. “We never get complacent, even when we achieve good results,” he says. “We’re always looking for ways to improve our performance.”
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AOPA NEWS
AOPAversity: Webinar Series Subscription 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.
AOPA Members Nonmembers
Price Per Seminar
$99.00* $199.00*
Price for Full Year
$990.00 $1,990.00
* 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.
MARCH 13
APRIL 10
Advanced Beneficiary Notice: Get To Know the ABN Form
Shoes, External Breast Prostheses, Surgical Dressings, and Other Policies
The advanced beneficiary notice (ABN) can be a valuable tool in protecting your financial liability. Take part in the March 13 AOPAversity webinar, when AOPA experts will examine proper usage of the ABN form: • Learn when use of an ABN is appropriate. • Examine common scenarios regarding proper ABN usage. • Determine how to use the ABN when billing for upgraded features. • Find out how the ABN can ensure a partial payment for services rendered. • Avoid the most common mistakes that can render an ABN invalid. • Understand all of the modifiers associated with an ABN.
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Sign Up for the 2019 Full Year Series & Save! Registration Fee
FEBRUARY 2019 | O&P ALMANAC
The April 10 webinar will cover some of the most frequently overlooked policies in O&P, including the Surgical Dressing Policy and the External Breast Prostheses Policy. Take part in the webinar and hear AOPA experts share their knowledge regarding these policies. • Review the nuances of the Therapeutic Shoes for Persons With Diabetes Policy. • Review the Orthopedic Shoe Policy, including a discussion regarding when the L3000 series of codes are covered. • Review the External Breast Prostheses Policy. • Learn when and how compression garments are covered.
AOPA NEWS
2019 WEBINARS
2019 AOPA Webinar Schedule Mark your calendars for AOPA’s 2019 monthly webinars. These informative sessions take place on the second Wednesday of each month at 1 p.m. EST. Upcoming 2019 Webinars • February 13: Patient Outcomes: Best Practices & How To Use Them • March 13: Advanced Beneficiary Notice (ABN): Get To Know the ABN Form • April 10: Shoes, External Breast Prostheses, Surgical Dressings, and Other Policies • May 8: Are You Compliant? Know the Supplier Standards • June 12: Documentation—Understanding Your Role • July 10: Target, Probe, Educate—Get To Know the Program & What the Results Are Telling You • August 14: Are You Ready for the Worst? Contingency Planning • September 11: Veterans Affairs Updates: Contracting, Special Reports, and Other News • October 9: Performance Reviews: How Is Your Staff Doing?
AOPA Announces 2019 Call for Papers Submissions Due March 25
AOPA is seeking high-quality educational and research content for the 2019 AOPA National Assembly, which will be held September 25-28, 2019, in San Diego, California. All submissions are due March 25, 2019. Your submissions will set the stage for a broad curriculum of high-value clinical and scientific offerings at the National Assembly. All free paper abstracts must be submitted electronically. Abstracts submitted by email or fax will not be considered. All abstracts will be considered for both podium and poster presentations. The review committee will grade each submission via a blind review process and reach a decision regarding acceptance of abstracts. AOPA is seeking submissions for the clinical free paper sessions, symposia/instructional courses, technician program, or business education program. Contact AOPA Headquarters at 571/431-0876 or rgleeson@AOPAnet.org with questions about the submission process or the AOPA National Assembly in general. Visit the AOPA website for more information and to see full submission guidelines for the 2019 AOPA National Assembly.
• November 13: The Holiday Season— How To Provide Compliant Gifts • December 11: New Codes for 2020, Other Updates, and Yearly Roundup During these one-hour sessions, AOPA experts provide the most up-to-date information on a specific topic. Webinars are perfect for the entire staff—they’re a great team-building, money-saving, and educational experience! Sign up for the entire series and get two conferences free. Entire Series ($990 Members/$1,990 Nonmembers). Register at bit.ly/2019webinars.
O&P ALMANAC | FEBRUARY 2019
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AOPA NEWS
NOW AVAILABLE:
‘2018 Operating Performance Report’ AOPA Releases Results From Member Benchmarking Survey
Are you curious about how your O&P business is performing compared to others? Have you been asking questions like these: • How does our spending on materials, advertising, or other expenses compare with other companies similar to ours? • Is our gross margin better or worse than other facilities of the same size? • Are our employees generating enough sales? Copies of the “2018 Operating Performance Report” are now available. The annual report provides a comprehensive financial profile of the O&P industry, including balance sheet, income statement, and payor information organized by total revenue size, community size, and profitability. This year’s data was submitted by more than 90 patient-care companies representing 1,022 full-time facilities and 191 part-time facilities. Copies of the “2018 Operating Performance Report” are available electronically in AOPA’s bookstore: • “2018 Operating Performance Report” (Electronic)—Member/Nonmember: $185/$325
NEW MEMBERS
T
HE OFFICERS AND DIRECTORS of
the American Orthotic & Prosthetic Association (AOPA) are pleased to present these applicants for membership. Each company will become an official member of AOPA if, within 30 days of publication, no objections are made regarding the company’s ability to meet the qualifications and requirements of membership. At the end of each new facility listing is the name of the certified or state-licensed practitioner who qualifies that patient-care facility for membership according to AOPA’s bylaws. Affiliate members do not require a certified or state-licensed practitioner to be eligible for membership. At the end of each new supplier member listing is the supplier level associated with that company. Supplier levels are based on annual gross sales volume.
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FEBRUARY 2019 | O&P ALMANAC
Integrum Inc. 100 Montgomery Street San Francisco, CA 94104 650/867-4487 Supplier 1 Transcend Orthotics & Prosthetics 134 Holiday Court, Ste.302 Annapolis, MD 21401 410/224-2000 Affiliate Transcend Orthotics & Prosthetics 1246 E. Walnut Lawn Street, Ste. 335 Springfield, MO 65804 417/755-7430 Affiliate
Transcend Orthotics & Prosthetics 230 Spring Hill Drive, Ste. 335 Spring, TX 77386 281/296-8999 Affiliate Pacific Medical P&O 1024 W. Robin Hood Drive, Ste. 2 Stockton, CA 95207 800/726-9180 Affiliate Thrive Prosthetics 6600 Coyle Avenue, Ste. 2 Carmichael, CA 95608 916/671-3417 Patient-Care Facility
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AOPA NEWS
CAREERS
Opportunities for O&P Professionals
Pediatric-Focused CO, BOCO, or CPO
Job location key: - 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
Job Board Member Nonmember $85 $150 For more opportunities, visit: http://jobs.aopanet.org.
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 e-mail: loyds@ix.netcom.com FEBRUARY 2019 | O&P ALMANAC
Pittsburgh, Pennsylvania De La Torre Orthotics and Prosthetics is seeking a pediatricfocused CO, BOCO, or CPO to join our growing pediatric orthotics practice. The qualified candidate will see patients in our local clinical offices, various PT departments, and rehab facilities in the greater Pittsburgh area. The candidate will be working primarily with children but will also have exposure to our adult patients. Requirements: • A minimum of two years of recent, successful patientbased experience in orthotics, preferably in pediatrics • Must work well in a team environment • Excellent oral communication skills with patients and referral sources • Ability to learn and use an EMR system • Experience with scoliosis, CP, spina bifida, pectus, plagiocephaly, and lower-extremity orthotics all a plus. De La Torre O&P offers competitive compensation and benefit packages including 401(k), medical, disability policies and certification reimbursement and is an AAP employer. Email résumé to jobs@delatorreop.com with subject line orthotist job.
Nonmember $678 $830
ONLINE: O&P Job Board Rates Visit the only online job board in the industry at jobs.AOPAnet.org.
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Mid-Atlantic
De La Torre Email: jobs@delatorreop.com Subject line: Orthotist job
Pacific
CPO
Southern California A well-established, privately owned, multioffice, ABCaccredited corporation is seeking experienced CPOs who will support the company’s vision, mission, and values and provide premier prosthetic and orthotic patient care to join our team. Candidates must be energetic, self-driven, motivated, and knowledgeable individuals who possess strong clinical, technical, and interpersonal interaction skills. They must be patient oriented and innovative, and desire a long-term career with a growing company. We offer competitive salaries, benefits, and a rewarding place to take the next step in establishing a great career and make a difference. Salaries are commensurate with experience. Local ABC-accredited practitioners are preferred. Apply by email to : Email: Box100@AOPAnet.org Reference Job ID: 45402723
AD INDEX
Advertisers Index Company
Page Phone
American Board for Certification in Orthotics, Prosthetics, and Pedorthics Allard USA ALPS South LLC Amfit Anatomical Concepts ARTech Laboratory Inc. Board of Certification/Accreditation Cascade Dafo Inc. ComfortFit Orthotic Labs Inc. Custom Composite ESP LLC Fabtech Systems LLC Ferrier Coupler Inc. Flo-Tech O&P Systems Inc. Hersco Kingsley Naked Prosthetics OHI Össur Ottobock Spinal Technology Inc. Surestep The Bremer Group Co. WillowWood
53 703/886-7114 27 866/678-6548 19 800/574-5426 23 800/356-3668 38 800/837-3888, 330/757-3569 39 888/775-5501 47 877/776-2200 7 800/848-7332 36 888/523-1600 13 866/273-2230 9 888/WEAR-ESP 30, 31 800/FABTECH 29 810/688-4292 43 800/356-8324 1 800/301-8275 45 800/854-3749 17 888/977-6693 11 877/780-8382 3 800/233-6263 C4 800/328-4058 15 800/253-7868 21 877/462-0711 37 800/428-2304 41 800/848-4930
Website www.abcop.org www.allardusa.com www.easyliner.com www.amfit.com www.anatomicalconceptsinc.com www.artechlab-prosthetics.com www.bocusa.org www.cascadedafo.com www.comfortlabs.com www.cc-mfg.com www.wearesp.com www.fabtechsystems.com www.ferrier.coupler.com www.1800flo-tech.com www.hersco.com www.kingsleymfg.com www.npdevices.com www.ohi.net www.ossur.com www.professionals.ottobockus.com www.spinaltech.com www.surestep.net www.bremergroup.com www.willowwoodco.com
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https://jobs.aopanet.org O&P ALMANAC | FEBRUARY 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
SOFTIE™ and SOFTIE-TF™
Break into the New Year with 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 start off a great New Year! Call us or visit www.easyliner.com for more details.
The Original Pre-Flexed Suspension Sleeve ESP created the Flexi family of suspension sleeves as a comfortable, durable, and cost-effective alternative to traditional suspension sleeves. Pre-flexed 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.
Sutti Bounders Store and 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 1-800/322-8234.
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FEBRUARY 2019 | O&P ALMANAC
Minimizing the effects of micro tears and/or injury to the incision area at bed rest holds a high priority. FLOTECH® designed the SOFTIE™ and SOFTIE-TF™ to aid easy access for wound care, and daily hygiene. We incorporated posterior struts to maximize extension control. Our SOFTIES assist healing and increase the quality of rehabilitation for postsurgical lower-limb amputees. The sockets are soft, nonconstricting, and easy to remove for examinations. Having an inventory of SOFTIE™ and SOFTIE-TF™ sockets allows you to fit most patients at a moment’s notice. They easily fit most sizes, including XL. For more information, visit www.1800flo-tech.com.
LEAP Balance Brace 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 Omo Neurexa Plus
Show Stopper Ever since its launch in 2016, Arizona Mezzo™ became an instant star in our lineup and the ideal solution to a decades-long problem for practitioners and patients alike. The happy medium between a UCBL and an Arizona Brace®, the custom-fabricated Arizona Mezzo provides support for a variety of midfoot and hindfoot conditions that require superior longitudinal arch support. Its low-profile design and soft leather lining mean easy shoe fit, exceptional comfort, and greater patient compliance. Partial Foot Arizona Mezzo is also available. For more information, contact Arizona AFO at 800/248-8817 or visit www.arizonaafo.com.
Proprio-Foot® 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.
New Caleo 3D 6Y95 Liner TPE comfort for your more active patients. The Caleo range has now been expanded to include a further version, the Caleo 3D 6Y95 liner. This liner with new gel formula is particularly suited to more active users due to its high level of durability and resistance to wear. • The 3D design features a thicker wall (6 mm) in the front for better protection, and a thinner wall (3 mm) at the rear for more flexibility. • New, improved gel formula combines durability and comfort, and can also be thermoformed. • Special knee flexion zone and mono-elastic textile elsewhere for reduced pistoning. For more information, call 800/328-4058 or visit www.professionals.ottobockus.com.
Redefine recovery with Ottobock's Omo Neurexa Plus. The shoulder orthosis facilitates active rehabilitation by correctly positioning the arm and promoting movement for patients with shoulder subluxation. The Omo Neurexa Plus inhibits pathological movement patterns, improves body posture and gait, and can be applied by patients themselves with one hand. For more information, call 800/328-4058 or visit professionals.ottobockus.com.
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
LimbLogic® M: Mechanical Vacuum Pump WillowWood’s LimbLogic M is the newest mechanical elevated vacuum solution for transtibial applications. This inline, mechanical vacuum pump has a low build height of 3.6 inches for flexibility in componentry selection and alignment. LimbLogic M offers: • Adjustable vacuum setting for optimal security and comfort • Shock absorption to reduce impact on limb • Adjustable stiffness to satisfy a range of weights and comfort preferences • 330-pound weight limit • Rotatable distal pyramid for easy alignment • Standard four-hole mount for simple and familiar set-up. For information, call 800/848-4930 or visit www.willowwoodco.com. O&P ALMANAC | FEBRUARY 2019
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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.
2019
March 25
AOPA National Assembly Call For Papers Deadline. For general inquiries, contact Ryan Gleeson at 571/431-0836 or rgleeson@AOPAnet.org, or visit www. AOPAnet.org.
April 1
ABC: Application Deadline for June Certification Exams. Applications must be received by April 1 for individuals seeking to take the June Written and Written Simulation certification exams. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.
April 1
ABC: Practitioner Residency Completion Deadline for Spring 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 www.abcop.org/certification.
April 8–13
February 13
Patient Outcomes: Best Practices & How To Use Them. Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR
ABC: Written and Written 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 300 locations nationwide. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.
NEW DATES: February 15–16
PrimeFare Central Regional Scientific Symposium 2019. Renaissance Hotel, Tulsa, OK. Contact Cathie Pruitt at 901/359-3936, email primecarepruitt@gmail.com; or Jane Edwards at 888/388-5243, email jledwards88@att.net; or visit www.primecareop.com.
Shoes, External Breast Prostheses, Surgical Dressings, and Other Policies. Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR
April 18–20
March 1
ABC: Application Deadline for Spring 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 www.abcop.org/certification.
March 1
ABC: Practitioner Residency Completion Deadline for April Written & Written Simulation 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 www.abcop.org/certification.
March 13
Advanced Beneficiary Notice (ABN): Get To Know the ABN Form. Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR
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April 10
FEBRUARY 2019 | O&P ALMANAC
International African-American Prosthetic Orthotic Coalition Annual Meeting. Texas Scottish Rite Hospital for Children, Dallas, TX. Contact Tony Thaxton Jr. at 404/875-0066, email thaxton.ir@comcast.net, or visit www.iaapoc.org.
May 1
ABC: Practitioner Residency Completion Deadline for June Written & Written Simulation 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 www.abcop.org/certification.
May 3–4
ABC: Orthotic Clinical Patient Management (CPM) Exam. ABC Testing Center, Tampa, FL. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.
CALENDAR
May 8
Are You Compliant? Know the WEBINAR Supplier Standards. Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.
September 25–28
AOPA National Assembly. San Diego Convention Center. For general inquiries, contact Ryan Gleeson at 571/431-0836 or rgleeson@AOPAnet.org, or visit www.AOPAnet.org.
May 17–18
ABC: Prosthetic Clinical Patient Management (CPM) Exam. ABC Testing Center, Tampa, FL. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.
June 3–4
Coding & Billing Seminar. Indianapolis, SEMINAR Indiana. Book your hotel by May 10 for the $189/night. For more information, email Ryan Gleeson at rgleeson@ AOPAnet.org.
October 9
Performance Reviews: How Is Your Staff Doing? Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR
November 3–9
Health-Care Compliance & Ethics Week. AOPA is celebrating Health-Care Compliance & Ethics Week and is providing resources to help members celebrate. Learn more at bit.ly/aopaethics.
June 12
Documentation—Understanding Your WEBINAR Role. Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.
July 10
Target, Probe, Educate—Get To Know the Program & What the Results Are Telling You. Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR
August 14
Are You Ready for the Worst? Contingency Planning. Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR
September 11
Veterans Affairs Updates: Contracting, WEBINAR Special Reports, and Other News. Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.
Calendar Rates CE For information on continuing education credits, contact the sponsor. Questions? Email ymazur@AOPAnet.org. CREDITS
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 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
2020 September 9–12
AOPA National Assembly. Mandalay Bay, Las Vegas. For general inquiries, contact Ryan Gleeson at 571/4310836 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
O&P ALMANAC | FEBRUARY 2019
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ASK AOPA CALENDAR
Counting the Audits Exploring the approved reviews, the new modifier rule, and more
AOPA receives hundreds of queries from readers Q and members who have questions about some aspect of the O&P industry. 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. How many different recovery audit contractor (RAC) audits are there?
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According to the website of Performant, the national home health, hospice, and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) contractor (Region 5), there are four different O&P-approved RAC audit issues as of Jan. 1, 2019. There are three complex reviews for the medical necessity for select custom-fabricated health-care common procedure coding system (HCPCS) codes: reviews for ankle-foot orthoses/knee-ankle-foot orthoses; lumbosacral orthoses/thoracolumbosacral orthoses; and knee orthoses. There also is one automated review for the reasonable useful lifetime of select spinal orthoses. To view a complete list of approved issues, visit the Performant website: https://performantrac.com/region-5/.
Q/
For claims with a date of service of March 1, 2019, and after, when providing bilateral items you will no longer submit the claim on a single line with two units of service and the RTLT modifier combination. Instead you must bill each item on a single line: one line with the LT modifier and one unit of service, and the other line with the RT modifier and one unit of service. For example, for a claim for bilateral double-upright knee orthoses, the claim may look like this:
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FEBRUARY 2019 | O&P ALMANAC
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What is the useful lifetime for an external breast prosthesis?
Typically, the useful lifetime for any item is five years, unless otherwise stated in a policy or piece of legislation. The external breast prosthesis policy has established the useful lifetime for certain breast prostheses under five years. For silicone breast prostheses, the useful lifetime is set at two years, and the useful lifetime for a nipple prosthesis is three months. For most other breast prostheses (e.g., fabric, foam, fiber, etc.), the useful lifetime expectancy is set at six months.
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Correct: L1846 KXRT x1 and L1846 KXLT x1
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60
What is the new modifier rule for bilateral services/items?
Incorrect: L1846 KXLTRT x2 Why aren’t the labor codes (L4205 and L7520) included on the most recent DMEPOS fee schedule update?
Q/
The L4205 and L7520 are calculated using a different method than the other HCPCS codes on the DMEPOS fee schedule; they are only subject to the consumer pricing index for urban areas (CPI-U) calculations and are released at a different time and on a different fee schedule. To view the current 2019 DMEPOS labor fees, visit https://www.cms.gov/ Regulations-and-Guidance/Guidance/ Transmittals/2018Downloads/R4181CP.pdf.
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If an item requires verification by the Pricing, Data Analysis, and Coding (PDAC) contractor and the product I wish to provide is not listed on the PDAC website, www.dmepdac.com, how do I bill Medicare for the item?
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The answer depends on the specific Medicare Medical Policy or PDAC coding guideline announcement that required the item to be verified and listed on the PDAC website. Typically, you would have to use code A9270 (noncovered item or service).
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