20 minute read
Reimbursement Page
by AOPA
CE credits accepted by certifying boards:
Individual NPI
How Type 1 identifiers can play a role in recognizing O&P professionals as allied healthcare providers
If you attend any meeting of the orthotic and prosthetic profession—whether a small local meeting, a midsized state or regional meeting, or a large national meeting—you will undoubtedly hear or participate in discussions regarding how O&P practitioners can gain recognition as the true allied healthcare providers they are.
For years, our profession has fought to be seen as more than just another supplier of medical equipment. O&P professionals often have as much as or more direct interaction with patients than other healthcare practitioners that have long been classified as allied health providers, and it is increasingly frustrating to continue to be pigeonholed into the durable medical equipment (DME)/supplier category.
One of the challenges the O&P profession faces when trying to achieve recognition as allied health practitioners is the fact that most payors only reimburse for completed prostheses or orthoses. Payment is based solely on the device and not on the time, knowledge, and expertise that contributes to the successful delivery of a well-fitting, properly functioning orthosis or prosthesis.
This is a challenge for which there is no easy solution. Discussions on the subject have prompted several suggestions, including completely separating the professional service of the orthotist or prosthetist; creating an entirely new reimbursement system for O&P services; or developing a hybrid solution that would provide partial reimbursement for the actual orthosis or prosthesis and additional reimbursement based on the time spent by the orthotist or prosthetist providing direct patient care.
The road to recognition as true allied health professionals is long, and the challenges are many, but one action that O&P practitioners can take now to prepare for the future is to obtain and utilize an individual National Provider Identifier (NPI).
NPI Evolution
The NPI was implemented in 2007 and 2008 as a result of the Administrative Simplification requirements of the Health Insurance Portability and Accountability Act. It was adopted as a single and unique number to identify an individual or healthcare entity in all healthcare transactions.
The NPI eliminated the need for separate provider numbers for each insurer with which a provider has an agreement. NPIs may be obtained, at no charge, through a simple online application process established by CMS via the National Plan and Provider Numeration System, available at nppes.cms.hhs.gov.
Two kinds of NPIs are available: Type 1, Individual Provider NPIs; and Type 2, Organization NPIs. Type 1 NPIs are used to identify individual physicians, practitioners, or sole proprietor-based business owners and are unique to a single person. Type 2 NPIs are used to identify healthcare entities such
as hospitals, nursing facilities, physician group practices, and suppliers of DME, prosthetics, orthotics, and supplies (DMEPOS).
Under existing Medicare and most private payor billing rules, O&P facilities are classified as a subset of DMEPOS suppliers and therefore submit claims using the Type 2 NPI number that is assigned to the business. There is no current requirement that warrants the application for and the use of Type 1 NPI numbers to identify the actual orthotist or prosthetist that delivered the patient care.
Limitations of Type 2 NPIs
The reliance on the use of Type 2 NPIs is an inherent barrier for prosthetists and orthotists to gain recognition as allied health providers. While physicians, physician assistants, nurse practitioners, and therapists all utilize their individual NPIs in addition to any Type 2 NPIs associated with their facility or practice, there has never been an established need for Type 1 NPI numbers to be reported on O&P claims.
AOPA and the American Academy of Orthotists and Prosthetists (AAOP) have established a task force to explore and promote the positive impact of orthotists and prosthetists obtaining an individual NPI and reporting it on claims submitted under the Type 2 NPI of the company for which they work. This task force has met several times and is in the process of creating resources to educate our respective memberships about the value of the individual NPI and how to obtain it.
There are currently no restrictions in place that prevent an individual orthotist or prosthetist from applying for and obtaining an individual NPI. Because the individual NPI is only associated with a single practitioner, it can be used to identify the practitioner even if they change employers. Obtaining an individual NPI has no impact on the use of a Type 2, entity-based NPI number to bill claims to Medicare or other payors.
An Important Step Forward
The pathway to recognition of orthotists and prosthetists as allied health providers is long and will require significant regulatory, administrative, and strategic work. The use of the individual NPI is just one step in this process, but it is one that can be done immediately with no disruption to current reimbursement models for O&P services.
AOPA and AAOP will continue to work together to promote the adoption of the individual NPI. As additional resources are developed, we will make sure that they are readily available for our members, and that appropriate support is available as we move forward toward this common goal.
Joe McTernan is director of health policy and advocacy at AOPA. Reach him at jmcternan@AOPAnet.org.
IN THEIR WORDS:
With the help of Charl Stenger, Orthomena (Spinal Technology’s partner in Dubai) the fitting I did of 2 braces remotely was excellent and showed good correction. I am so pleased with the easiness of fitting and hope this is the beginning of our business together.
- Dr. Waeel Abdalla M.D. D.C., Egypt
508-957-8310 Spinal.Tech/Testimonials
LEADING THE GREAT RENEGOTIATION
Improve workplace culture to counteract trends in resignations, employee burnout, quiet quitting, and more
The years 2021 and 2022 saw record numbers of workers resigning, with an average of 4 million Americans quitting their jobs each month—a startling 96 million employees leaving their jobs over the past two years.
These trends are particularly troubling for the O&P profession, where the need for clinicians is rising. With an aging baby boomer population and expected clinician retirements on a collision course, the possibility of a future O&P clinician shortage looms large. Employment for orthotists and prosthetists is projected to grow 17% from 2021 to 2031, according to the Bureau of Labor Statistics (BLS), with 1,000 job openings projected each year, on average, over the decade. “Many of those openings are expected to result from the need to replace workers who transfer to different occupations or exit the labor force, such as to retire,” according to BLS.
NEED TO KNOW:
fEmployment trends have shifted dramatically over the past few years, with millions of Americans quitting their jobs each month, and record numbers of employees “quiet quitting” or experiencing emotional burnout. f In this tight and rapidly shifting climate, O&P businesses should take a hard look at their employee retainment practices and ensure their workplace culture meets the needs of current staff and prospective employees. f Companies that foster community and offer flexible options—for example, self-determined hours and remote work— are more attractive to workers, so O&P facilities should consider adopting some of these perks. f It’s also important to demonstrate empathy to young workers, to maximize new employees’ strengths when considering workflow, and to offer training and growth opportunities.
Disengaged, Disenchanted
In recent years, some facilities have noted more students graduating from O&P master’s programs—but exiting clinical practice within the first few years, says Mark Ford, president of Catdaddy Consulting Services.
When the profession evolved to a master’s requirement for O&P certification—necessitating a graduate degree that can cost up to $170,000, according to the International Institute of Orthotics and Prosthetics—salaries remained stagnant. (The most recent data from the BLS reports a median annual salary of $75,440.) New clinicians are expecting their wages to cover comfortable living conditions and student loan repayments—but most facilities are not prepared to offer salaries commensurate with new hires’ expectations, says Ford. As a result, he has witnessed many young clinicians leaving positions at patient-care facilities for jobs on the manufacturing side of O&P, where salaries are typically higher.
On the other end of the clinician age spectrum, some older clinicians “aren’t having as much fun” practicing O&P now that documentation requirements are so encompassing, says Ford. Those who, years ago, chose the profession to combine patient care with hand skills now are spending more time using CAD and completing documentation—and less time fabricating and seeing patients. This trend, combined with rising mergers and acquisitions, has triggered “a growing number of experienced clinicians” to sell or leave their O&P practices, according to Ford.
In addition to the clinicians who actually exit the profession, recent data shows many of those who remain in their jobs are experiencing emotional burnout or engaging in “quiet quitting,” both of which significantly hurt productivity—and could lead to future resignations. While burnout is defined as a state of physical or emotional exhaustion that involves a sense of reduced accomplishment and loss of personal identity, quiet quitting is an intentional choice: The employee chooses to stay in their job but puts in no more effort than absolutely necessary.
Young clinicians are particularly vulnerable to both emotional burnout and quiet quitting behaviors, according to Gerald Stark, PhD, MSEM, CPO, LPO, who has conducted several surveys of more than 400 O&P professionals concerning both issues. Stark, who is director of clinical affairs at Ottobock Patient Care and adjunct instructor at the University of Tennessee at Chattanooga, found that almost one-third (29%) of respondents are at “severe risk or higher of burnout,” and 8% are at “levels of burnout that are affecting mental and physical health.” These rates are higher than burnout scores captured among physical and occupational therapists, according to Stark. He is particularly concerned
about clinicians with five or fewer years of experience, who reported the second highest rates of burnout and anxiety. “If clinicians are burned out at a young age, what happens when they reach the typical time of career burnout in 10 to 15 years? This could definitely lead to more attrition in O&P later, when we need them most,” he says. In fact, Stark’s data points to specific factors that influence the risk for burnout: the dramatically higher volume of documentation needed per patient to support reimbursement; pressure from Mark Ford management to meet monthly income goals; the personal cost of entry to the profession; and the large amount of knowledge needed to practice orthotics and prosthetics immediately. “Previously, we started with one discipline, then added the other,” explains Stark. “New students are expected to practice it all.” Stark’s December 2022 survey shows reasons to be concerned about quiet quitting as well. Between 15% and 20% of respondents reported they had reduced their work “to the point that others had noticed, but they didn’t care that it was obvious to co-workers,” he says. “Work/life balance is one thing, but when you can’t function at the level of work that is expected, that’s a problem for the entire organization. Quiet quitting causes communication—and, subsequently, innovation—to slow, and can cause downturn in patient care.” Quiet quitting may be a tough challenge for the profession, Stark adds, “because O&P professionals are usually not rewarded for their quality of work. Instead, employers may only measure productivity by the revenue they produce” because businesses are paid by device. “In a sense, clinicians value themselves based on how effective and inventive they are in patient care, but the organization tends to value them in another way,” with insurers reimbursing by device delivery and not quality of care. That dichotomy can make it hard for clinicians to go above-and-beyond to deliver differentiated, high-quality patient care. Gerald Stark, PhD, MSEM, CPO, LPO Lesleigh Sisson, CFo, CFm
Reimagine, Revitalize
Considering recent trends in employee shortages and decreased productivity, it’s more important than ever that O&P companies focus on retention, recognize signs of employee dissatisfaction, and remain mindful of how company culture impacts prospects and employees.
How can O&P companies accomplish these goals? This is a complicated problem with no clear answer, but O&P consultants, educators, and experts suggest these strategies:
Set expectations and define job responsibilities early. No two O&P facilities are alike, so O&P managers should clearly communicate what will be required of new hires, says Lesleigh Sisson, CFo, CFm, president of Prosthetic Center of Excellence in Las Vegas and founding partner of consulting firm O&P Insight. “Not all CPO roles are created equal.
Prevent Workplace Harassment to Retain Employees
Thomas Karolewski, CP, LP, FAAOP, past chair of NCOPE and owner of Legmaker Pro, an O&P consulting service, is currently studying harassment trends in O&P education and the O&P workforce while pursuing his doctoral degree.
Two years ago, he conducted a “negative acts survey” and discovered anecdotal evidence of many O&P professionals expeThomas Karolewski, CP, LP, FAAOP riencing discriminatory behavior, with some choosing to leave the profession altogether after experiencing harassment. Identifying this “disturbing trend” prompted Karolewski to follow up with a dissertation on how people respond to harassment in O&P. “I’m interviewing individuals who are in the field on how they responded to bullying.” Karolewski says he recently interviewed three young clinicians who left the field soon after residency due to both “bullying” and low wages. “One person told me that out of [an O&P master’s program] graduating class of 20, five had left the field,” he says. Another young clinician reported that about one-eighth of their graduating class had already left the profession. The attrition rates among recent O&P master’s program graduates warrant more consideration. Karolewski believes retainment of O&P clinicians will require more attention to harassment challenges and more transparent conversations about salaries.
“Older people don’t realize that millennials have plenty of time to make corrections with their careers,” he says. “The average millennial only stays at a job five to seven years, so we have to focus on ensuring young clinicians stay engaged.” O&P facilities should recognize the “generational cavern” between older clinicians who earned O&P certificates and recent O&P graduates, he says. Facilities should be sure to foster a workplace with respect for each other’s strengths and a willingness to collaborate. “It’s important to provide a good working environment” so people want to do their jobs.
Some clinicians in urban environments must go from hospital, to nursing home, to clinic, working long hours. In rural areas, clinicians may need to drive significant distances to see patients,” while others may be expected to have more traditional 8-to-5 jobs, she says. “So, employers will need to set expectations appropriately.”
Match young clinicians with appropriate tasks. Set up young clinicians for success, rather than failure, by empowering them to excel in work they are familiar with. J. Chad Duncan, PhD, CRC, CPO, department chair of orthotics-prosthetics at the new Salus University O&P master’s program, suggests reevaluating workflow to maximize new employees’ strengths, create an efficient work environment, and avoid new clinicians feeling underutilized.
“The quality of students today is very high,” and new graduates have a lot to offer, says Duncan. However, some companies may have unrealistic expectations about young clinicians’ abilities. Current students may not have as much fabrication experience as previous generations, but many young clinicians enter the profession with engineering backgrounds, programming skills, and experience in scanning, CAD, and 3D printing.
J. Chad Duncan, PhD, CRC, CPO
Companies that “slow down” the process of integrating new employees into the facility can benefit, according to Duncan. “Students today may not be as strong in fabrication, but they can see patients, scan, and develop their clinical skills slowly,” while leveraging their programming and CAD skills to contribute to their companies’ success.
Ford encourages facilities to “give availability and time for new clinicians to learn as much as they can as fast as they can.” Many facilities allocate easier, lower-end work, such as fitting AFOs, to new hires—which can be “boring,” says Ford. He suggests that facilities intersperse this necessary work with more high-tech cases “to keep their interest level high” and demonstrate that they will have opportunities to learn advanced O&P.
Value the contributions of care extenders and other staff members. Ford suggests that O&P facilities “get serious about care extenders” as an integral part of the office. Care extenders can be used to handle some aspects of patient care, capture and record outcome measures, and more—all at lower salaries than certified clinicians.
Hiring technicians, assistants, and fitters is “a great way to expand clinical staff” and provide support to orthotists and prosthetists, as long as appropriate in-house training and oversight is available, agrees Sisson. “Look at alternative ways for O&P practitioners to have extended staff—and to become more of the ‘overseers’ rather than always the ‘doers.’”
Sisson also recommends hiring and training well-qualified administrative staff to help manage the intricacies of proper O&P documentation and billing—thus freeing up time for clinicians to focus on patient care.
Offer flexibility. Gen Z and millennials have a different mindset that is not bound by the traditional 9-to-5 schedule, says Duncan. Young professionals “do not connect with punching clocks,” he says. They also recognize that other professions offer remote work and would welcome opportunities to work from home on occasion—for example, for meetings, when completing documentation (in accordance with HIPAA guidelines), or for virtual consultations.
Another way to offer flexibility is to consider a four-day workweek—a movement that is gaining some momentum. A recent trial of the four-day workweek in the United States and Ireland had positive results. Thirty-three companies with more than 900 employees collectively took part in a six-month pilot program rolled out by 4-Day Week Global, in which workers were given 100% pay for logging 80% of their normal hours. Despite the reduced hours worked, average revenue increased by 38%, absentee days decreased, and resignations fell. Nearly all employees wanted to keep the four-day workweek; they reported stronger work performance, a decrease in burnout levels, and improved work-life balance.
Experiments like this could be adopted within the O&P workplace, perhaps by offering four-day workweeks with extended hours— something companies should consider to remain competitive.
Empathize with young workers. “We have to think about the context of our workers,” and recognize that Gen Z and millennial employees may have different expectations about work/life balance than their older counterpoints, says Stark. “We need to have greater empathy for their holistic career expectations, and recognize they may be carrying a large debt load,” he says. “They also want to know how you are going to help them grow as professionals. If we don’t, they are simply more prone to go somewhere else” to find that growth opportunity.
Tailoring O&P Education for Future Patient Care
At the new Midwestern University O&P master’s program, Director Christopher Hovorka, PhD, CPO, FAAOP, has been studying O&P industry trends and is designing curricula to prepare future clinicians for client-patient care in 2030 and beyond. The new courses will help the program, which is currently pursuing NCOPE accreditation and plans to accept its first cohort in the fall, prepare students for the realities of working in the profession.
Hovorka examined trends in O&P, technology, and healthcare in general, and he considered what skills and competencies will be needed five to 10 years from now. In a “sobering and enlightening” undertaking, he spoke with managers at bigger O&P facilities as well as general healthcare innovators and engineers, wearable tech manufacturers, educators, reimbursement professionals, and policymakers.
He noted a conundrum: Although the O&P profession is “device-anchored for reimbursement,” client-patients are demanding more holistically informed and personalized care from their healthcare providers. Hovorka believes O&P providers in the future “can offer a value-added difference compared to disruptors entering the market by being a client-patient centered care provider, within a devicecentric reimbursement model.” One potential complementary option is the boutique care model, an alternative approach to pricing. Clientpatients forgo insurance and pay a set fee per year for “concierge service, and unfettered access” to clinical care, suggests Hovorka. If this model is found to be a legally acceptable practice within O&P, some O&P companies that are willing to offer both traditional and boutique pricing options could find success in geographic areas with wealthier populations, Hovorka notes.
The Midwestern program also will prepare clinicians-to-be to compete in an increasingly digital world, and to serve client-patients outside of regular
geographic boundaries when digital options are appropriate. Considerations such as these are guiding Hovorka and his team in informing new care delivery models in coursework—to focus on the value added by strategic personal interactions and client-patientcentered care. “We are evolving from a device provider to a clinical care provider,” but are still limited by a device-centric reimbursement model, Hovorka says. O&P master’s curricula will have to evolve as well. “If we can consider new complementary models of care, such as boutique practice to supplement” traditional reimbursement models and Christopher Hovorka, PhD, CPO, FAAOP consider branching out to new markets that might seek boutique care, then O&P facilities can expand their target market with client-patient-centric care. This will require greater efficiencies in the O&P device design and manufacturing processes by leveraging the use of digital technologies that improve the reliability of manufacturing, when appropriate, to reduce the cost of doing business, according to Hovorka.
First cohort of O&P master’s students at Salus University, which began classes last fall
Sisson notes that empathy goes both ways. Young clinicians should be encouraged to be self-reflective and self-aware, and to “not discount the older clinicians who don’t have master’s degrees,” she says. “I cannot express enough the need to value what each staff member brings to the team.”
Foster community. Stark advises business owners to “work more on individual communication,” and create community within the workplace—doing so can be particularly effective at mitigating burnout and boosting a sense of connectedness that can prevent quiet quitting. “This doesn’t mean we don’t challenge people—quite the opposite: People want to do great things but just need help managing the anxiety that innovation naturally presents.
“Relationships and career development are the main ways we can achieve personal and professional transformation,” so O&P leaders should encourage staff members to work collaboratively, adds Stark. “When employees become isolated, they’re in danger of falling into a pit of uncontrolled anxiety. If COVID taught us something, [it’s that] we need each other to distribute and endure the anxiety of a quickly changing world.”
Consider wage adjustments or other incentives. O&P companies should be aware that U.S. employers are planning to increase their salary budgets by 4.6% for 2023, the highest annual jump in 23 years, according to a survey from consulting firm Willis Towers Watson. Most companies attribute the expected increase to inflation and a tight labor market. In addition, some U.S. companies recently offered, or are planning to offer, “inflation bonuses” to assist their employees with the rising cost of living.
It’s time for O&P facilities to examine their financials to see if salary bumps or bonuses are a possibility. Alternatively, “some facilities are finding creative ways to incentivize clinicians,” says Ford. Some employers are measuring individual performance and empowering clinicians to earn additional income if they meet certain benchmarks—for example, seeing more patients, boosting patient satisfaction scores, or successfully fitting patients in fewer visits, Ford explains.
Support O&P master’s programs. One of the bright spots when predicting future employment in O&P is the recent addition of O&P master’s programs, which will enable more prospective clinicians to earn their degrees. Two new O&P master’s programs have opened—one at Salus University, which accepted its first cohort last fall, and one at Midwestern University, which will accept its first students for fall 2023. These programs should boost the numbers of students who will be eligible to be certified after they complete their residencies.
Expand efforts to create a diverse and inclusive workplace. O&P is primed to become a more diverse profession, given the current population at O&P schools, says Ford. Hiring and retaining female clinicians and clinicians of color will be a critical next step. “We need to think about how we support [the current diversity of students] so that we can keep diverse folks in the field, and we can improve how we relate to patients,” he says.
“Know your workplace culture, and develop safe spaces for people to learn about each other in an open and humble environment,” agrees Duncan. “Owners and managers have to be open to diversity, and create environments where people feel they can belong. It makes us a stronger profession to be more diverse professionally; it brings diverse thought and diverse solutions.”
Christine Umbrell is a contributing writer to O&P Almanac. Reach her at cumbrell@contentcommunicators.com.
