REIMBURSEMENT PAGE
By JOE MCTERNAN
Bracing for Impact How will prior authorization, competitive bidding, and other trends affect your O&P business?
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 16 to take the Reimbursement Page quiz. Receive a score of at least 80%, and AOPA will transmit the information to the certifying boards.
E! QUIZ M EARN
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NE OF THE CHALLENGES in
today’s fast-evolving business environment is understanding how changes that are happening today will impact your business in the future. This is especially true for O&P businesses, which have faced several significant changes in recent months. Changes are not necessarily bad for business, but how you react and adjust to change will determine how successfully your business navigates change. This month’s Reimbursement Page reviews some of the changes and trends impacting the O&P business world and discusses how they may affect your facility in the future.
can be frustrating, it also provides an opportunity to adjust your business practices based on the quickly emerging trend. If prior authorization requests are not receiving affirmations, then it may be time to provide additional education to your referral sources and adjust how you document in your own records. At the moment, Medicare prior authorization for orthotics is limited to five orthosis codes, but it is likely the program will be expanded. Learning how to improve your chances for success with a limited number of impacted Healthcare Common Procedure Coding System codes will pay dividends as Medicare prior authorization expands to other areas.
Prior Authorization
Competitive Bidding
Medicare prior authorization is a relatively new program for O&P services and is currently limited to six lower-limb prosthesis codes, two spinal orthosis codes, and three knee orthosis codes. While the Medicare prior authorization program has gone very well for lower-limb prostheses, with almost all requests receiving affirmation upon the initial submission, prior authorization requests for spinal and knee orthoses have proven to be a bit more difficult. Issues that have caused denials in the past, such as the lack of measurable objective joint laxity in osteoarthritic knees, are lowering the initial affirmation rates for orthoses that now require Medicare prior authorization as a condition of payment. While this situation 14
AUGUST 2022 | O&P ALMANAC
The Medicare competitive bidding program is viewed by many as a tremendously successful program—not only for O&P services, but for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) in general. Currently, only off-the shelf (OTS) orthoses remain subject to Medicare competitive bidding. The most recent round of competitive bidding, also known as Round 2021, removed all of the DMEPOS categories that were previously subject to Medicare competitive bidding. The stated reason for this was that competitive bidding resulted in significant cost savings, and future rounds of competitive bidding would most likely not lead to additional savings to the Medicare program.
