July 2018 O&P Almanac by AOPA

The Magazine for the Orthotics & Prosthetics Profession

J U LY 2018

E! QU IZ M

Lessons Learned From the TPE Program Rollout

EARN

BUSINESS CE

CREDITS PP. 20 & 46

P.18

Why Peer Mentoring Works P.32

Preview Clinical and Business Education Sessions Planned for Vancouver P.38

How To Handle Medicare As a Secondary Payor

SENIOR SURGE

FACILITIES PREPARE FOR AN INFLUX OF BABY BOOMERS IN NEED OF O&P INTERVENTION P.24

WWW.AOPANET.ORG

P.44

This Just In: Next Steps for the Recognition of O&P Clinician Notes P.22

YOUR CONNECTION TO

EVERYTHING O&P

THE PREMIER MEETING FOR ORTHOTIC, PROSTHETIC, AND PEDORTHIC PROFESSIONALS.

TION STRA I G E R

OPEN

tio forma ore in For m pp.13 & 38 see

PASSPORT

INNOVATION

Vancouver is easy to explore during your time at the downtown Vancouver Convention Centre as there are many nearby top attractions. • • • • • •

Capilano Suspension Bridge Vancouver Aquarium Forbidden Vancouver Stanley Park Horse-Drawn Tours Harbour Cruises & Events Flyover Canada

• Vancouver Lookout • Dr. Sun Yat-Sen Classical Chinese Garden • Vancouver Art Gallery • Science World • Grouse Mountain

Experience Beyond Vancouver’s unbeatable location makes it the perfect gateway to the rest of British Columbia and beyond, providing you with outstanding opportunities for pre- and post-conference travel. • Whistler • Okanagan Valley • Jasper • Victoria • Banff • Cruise to Alaska

AOPAnet.org

#AOPA2018

Experience all the AOPA National Assembly has to offer while visiting Vancouver.

A simple way to make life easier. easy 3d scans Structure Sensor

Download App

Scan & Send 800.301.8275

Orthotics ● AFOs ● Richies ● 3D Scanning

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contents

J U LY 2018 | VOL. 67, NO. 7

FEATURES

JULY 2018 | O&P ALMANAC

COVER STORY

24 | Senior Surge Health-care facilities across the nation are experiencing an uptick in senior patients, including a growing cadre of baby boomers. O&P professionals should be prepared to meet the growing orthotic and prosthetic needs of these older patients, who may present with more co-morbidities, skin challenges, and joint degradation issues than their younger counterparts. By Christine Umbrell

22 | This Just In

Official Recognition February 2018 marked a significant milestone for the O&P profession, when one of seven provisions of the Medicare O&P Improvement Act was enacted recognizing O&P notes as part of the medical record. Efforts from AOPA and its lobbying team in seeking guidance from CMS on “next steps” have led to instructions from Alec Alexander, CMS’s deputy administrator and director of program integrity, to implement the provision immediately.

32 | Shared Experiences Many patients with limb loss are benefiting from participation in peer mentoring programs designed to match them with amputee mentors who help ease the transition to life with a prosthesis. Peer mentors—such as individuals certified as Peer Visitors by the Amputee Coalition—serve as role models who can help new or struggling amputees identify coping mechanisms and set achievable mobility goals. By Meghan Holohan

38 | Hot Topics Preview some of the most thought-provoking and informative educational sessions planned for the 2018 AOPA National Assembly in Vancouver. From clinical sessions centered on evidence-based research, to business sessions with tips for maximizing profits, to pedorthicand fabrication-focused sessions, the curriculum has something for everyone. By Meghan Holohan

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contents

PRINCIPAL INVESTIGATOR Kenton R. Kaufman, PhD, PE..........48 A widely recognized O&P researcher from the Mayo Clinic shares his experiences in musculoskeletal studies and componentry design.

DEPARTMENTS Views From AOPA Leadership..........5 David Boone, MPH, PhD, advocates for more evidence-based research

AOPA Contacts.......................................... 6 How to reach staff

Numbers......................................................... 8 At-a-glance statistics and data

Happenings............................................... 10 Research, updates, and industry news

COLUMNS Reimbursement Page..........................18 Lessons Learned From the TPE Program

Analysis of the preliminary findings from Noridian

CE Opportunity to earn up to two CE credits by taking the online quiz.

CREDITS

P.12 Compliance Corner.............................. 44

Secondary Status

Identifying payors that are primary to Medicare CE Opportunity to earn up to two CE credits by taking the online quiz.

CREDITS

People & Places........................................16 Transitions in the profession P.52

Member Spotlight................................. 52 n

North Carolina Orthotics & Prosthetics Surestep

AOPA News...............................................56 AOPA meetings, announcements, member benefits, and more

PAC Update............................................... 57 Welcome New Members................... 57 Careers.........................................................58 Professional opportunities

Marketplace............................................. 60 Ad Index.......................................................61 Calendar..................................................... 62 Upcoming meetings and events P.18

Ask AOPA.................................................. 64 P.54

JULY 2018 | O&P ALMANAC

Under what circumstances are shared spaces allowed?

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 Chris Nolan Ottobock, Austin, TX Vice President Jeffrey Lutz, CPO Hanger Clinic, Lafayette, LA Immediate Past President Michael Oros, CPO, FAAOP Scheck and Siress O&P Inc., Oakbrook Terrace, IL Treasurer Jeff Collins, CPA Cascade Orthopedic Supply Inc., Chico, CA Executive Director/Secretary Thomas F. Fise, JD AOPA, Alexandria, VA DIRECTORS David A. Boone, MPH, PhD, BSPO Orthocare Innovations LLC, Edmonds, WA Jeffrey M. Brandt, CPO Ability Prosthetics & Orthotics Inc., Exton, PA Mitchell Dobson, CPO, FAAOP Hanger Clinic, Grain Valley, MO Traci Dralle, CFM Fillauer Companies, Chattanooga, TN Teri Kuffel, JD Arise Orthotics & Prosthetics Inc., Blaine, MN

Support for Evidence-Based Practice

HAT USED TO BE primarily an academic question of establishing scientific facts is now an imperative for all O&P clinicians. “Evidence-based practice” is the umbrella term we use. O&P is evolving with the rest of the medical world to require practice based on ever more and better information. In the past, the best clinicians already based their treatment practices on evidence, though it was generally the evidence gleaned tacitly through years of doing their best for their patients. They individually interpreted the successes and failures they witnessed. The result was some really excellent care in some instances and some not so optimal care in others. Even in the best of cases, the clinical wisdom used was not necessarily passed on very well. In today’s world, where we expect to have access to the best, correct information on demand, we need to build a public body of proven best practices. This is the basis by which professional organizations like AOPA prioritize supporting research. Research is the systematic evaluation of facts through the scientific method. It takes many forms—from examining rarefied theoretical questions to very downto-earth, basic descriptions of our patient populations. The common theme is careful attention to unbiased methods and reporting. AOPA sponsors targeted research through granting mechanisms that are specific to the key questions of the day faced by our members. To find answers to clinical questions, we need multiple tests, careful reporting, and peer review to be added to the knowledge base for practice. Multiple studies are required, too, as each research study rarely fully answers all the nuances of treating complex human beings. Put together, each study sponsored through the ongoing grant support of AOPA adds a piece to the puzzle before us. Another aspect of supporting research is that one good study begets another. We are sowing seeds of understanding that will grow far beyond the limits of one study. Research capacity is developed, and researchers build on the work of those before them. Questions and methods are refined over time, and the result is better research with better answers. Taken all together, these are the reasons that AOPA has made a significant financial commitment to help the entire O&P field through ongoing research support.

David Boone, MPH, PhD, BSPO, is clinical director at AOPA.

Dave McGill Össur Americas, Foothill Ranch, CA Rick Riley Thuasne USA, Bakersfield, CA Brad Ruhl Ottobock, Austin, TX

Access Important Research

Visit www.AOPAnet.org/resources/research for links to groundbreaking industry research, including the RAND Corporation's “Economic Value of Advanced Transfemoral Prosthetics” value simulation and data regarding the provision and utilization of O&P services from Dobson DaVanzo & Associates, LLC, and AOPA.

O&P ALMANAC | JULY 2018

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 Thomas F. Fise, JD Editorial Management Content Communicators LLC

Our Mission Statement Through advocacy, research and education, AOPA improves patient access to quality orthotic and prosthetic care.

Advertising Sales RH Media LLC Design & Production Marinoff Design LLC Printing Sheridan

Our Core Objectives AOPA has three core objectives—Protect, Promote, and Provide. These core objectives establish the foundation of the strategic business plan. AOPA encourages members to participate with our efforts to ensure these objectives are met.

EXECUTIVE OFFICES

SPECIAL PROJECTS

Thomas F. Fise, JD, executive director, 571/431-0802, tfise@AOPAnet.org

Ashlie White, MA, manager of projects, 571/431-0812, awhite@AOPAnet.org

Tina Carlson, CMP, chief operating officer, 571/431-0808, tcarlson@AOPAnet.org Don DeBolt, chief financial officer, 571/431-0814, ddebolt@AOPAnet.org

Reimbursement/Coding: 571/431-0833, www.LCodeSearch.com

MEMBERSHIP & MEETINGS

O&P ALMANAC

Kelly O’Neill, CEM, manager of membership and meetings, 571/431-0852, kelly.oneill@AOPAnet.org

Thomas F. Fise, JD, publisher, 571/431-0802, tfise@AOPAnet.org

Betty Leppin, manager of member services and operations, 571/431-0810, bleppin@AOPAnet.org Yelena Mazur, communications specialist, 571/431-0876, ymazur@AOPAnet.org Ryan Gleeson, CMP, assistant manager of meetings, 571/431-0876, rgleeson@AOPAnet.org AOPA Bookstore: 571/431-0876

Josephine Rossi, editor, 703/662-5828, jrossi@contentcommunicators.com Catherine Marinoff, art director, 786/252-1667, catherine@marinoffdesign.com Bob Heiman, director of sales, 856/673-4000, bob.rhmedia@comcast.net Christine Umbrell, editorial/production associate and contributing writer, 703/6625828, cumbrell@contentcommunicators.com

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 landerson@AOPAnet.org. Yearly subscription rates: $59 domestic, $99 foreign. All foreign subscriptions must be prepaid in U.S. currency, and payment should come from a U.S. affiliate bank. A $35 processing fee must be added for non-affiliate bank checks. O&P Almanac does not issue refunds. Periodical postage paid at Alexandria, VA, and additional mailing offices. ADDRESS CHANGES POSTMASTER: Send address changes to: O&P Almanac, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314. Copyright © 2018 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.

REIMBURSEMENT SERVICES Joe McTernan, director of coding and reimbursement services, education, and programming, 571/431-0811, jmcternan@AOPAnet.org Devon Bernard, assistant director of coding and reimbursement services, education, and programming, 571/431-0854, dbernard@AOPAnet.org 6

JULY 2018 | O&P ALMANAC

Advertise With Us! Reach out to AOPA’s membership and more than 11,800 subscribers. Engage the profession today. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net. Visit bit.ly/almanac18 for advertising options!

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NUMBERS

The Graying of the O&P Patient Population TRENDING OLDER

20 Percent

Approximately 1 in 5 U.S. residents will be retirement age by 2030.

INCREASED LIFE EXPECTANCIES

~20 Years

Persons reaching age 65 today have an average life expectancy of an additional 19.4 years.

100

>65

All baby boomers will be older than 65 by the year 2030.

81,896

Number of persons age 100 or older in the United States in 2016.

HEALTH OUTLOOK

>50 Percent

In 2030, the number of people with diabetes will increase by about 55 percent as baby boomers become senior citizens.

From Pyramid to Pillar: A Century of Change The number of older Americans is rising rapidly

1 in 10

Approximately 9 percent fewer senior citizens will be likely to say they have “very good” health in 2030.

“The aging of baby boomers means that within just a couple decades, older people are projected to outnumber children for the first time in U.S. history. … By 2035, there will be 78.0 million people 65 years and older compared to 76.4 million under the age of 18.” —Jonathan Vespa, a demographer with the U.S. Census Bureau

SOURCE: National Population Projections, 2017, U.S. Census Bureau

JULY 2018 | O&P ALMANAC

SOURCES: U.S. Census Bureau’s National Population Projections; United Health Foundation; “2017 Profile of Older Americans,” Administration for Community Living and Administration on Aging.

The nation’s population has an older age profile compared to just 16 years ago, according to the U.S. Census Bureau. Baby boomers began turning 65 in 2011, and a significant segment of this population is now frequenting O&P facilities on a regular basis. O&P clinicians should be aware of the trend and be prepared to meet the needs of the growing senior population.

The clinically proven pocket-sized 3D image capturing system. The Apple® iPhone® and the Prosthetic Module are the latest additions to the SmartSoc 3D Capturing System from Orthomerica. Clinicians now have the freedom to choose where they send their prosthetic scans for manufacturing including Orthomerica, custom fabrication facilities, or their own labs. SmartCam™ for fast, safe, and accurate video scans • Samsung® Galaxy S7® with Android™ OS -orApple iPhone 7 with iOS®* • User friendly—requires minimal training to use • Accurate to 0.1% • Generic model on the device display shows real-time SmartScan™ progress • Scanning halo turns green, indicating optimal stand-off distance • Allows patient movement during a SmartScan • Portable—easily taken to clinics and satellite offices CurveCapture™ App converts 2D video images to a 3D model • Revolutionary technology analyzes 2D video images for optimal 3D conversion in the cloud • HIPAA compliant eBrace® web portal • Allows users to review the 3D Model • Platform for ordering STAR® family of cranial remolding orthoses from Orthomerica and sending prosthetic scans to third-party fabricators Product offerings • Prosthetics • STAR family of cranial remolding orthoses • Custom protective helmets • More modules to come! The SmartSoc System eliminates the need to take messy, expensive, time-consuming, & less accurate plaster casts.

U.S. Patent: 14/062,994 & Patents Pending

Happenings RESEARCH ROUNDUP

Researchers Set the Stage for More Intuitive Prosthetic Hands A team of researchers from the joint biomedical engineering program at North Carolina State University and the University of North Carolina at Chapel Hill has developed new technology designed to decode neuromuscular signals to aid in controlling prosthetic hands and wrists. Led by He (Helen) Huang, PhD, the new technology—which has not yet entered the clinical trial phase—may one day provide an alternative to pattern recognition control. The researchers have developed computer models that closely mimic the behavior of natural structures in the forearm, wrist, and hand. They designed a user-generic, musculoskeletal model, then enlisted six able-bodied volunteers to participate in a study. Researchers placed electromyography sensors on the participants’ forearms and tracked which neuromuscular signals were sent when the individuals performed actions using their wrists and arms. Using this data, the researchers created a generic model that translates those neuromuscular signals into commands that control a powered prosthesis. While pattern recognition control requires patients to “train” their

prostheses, the new technology is designed to be more intuitive, according to Huang. “When someone loses a hand, their brain is networked as if the hand is still there,” she said. “So, if someone wants to pick up a glass of water, the brain still sends those signals to the forearm. We use sensors to pick up those signals and then convey that data to a computer, where it is fed into a virtual musculoskeletal model. The model takes the place of the muscles, joints, and bones, calculating the

FAST FACTS

AMPUTATION IN THE UNITED STATES

2.1 million

people are living with limb loss.

Each year,

185,000

people have an amputation.

SOURCE: “Limb Loss in the USA,” Amputee Coalition

JULY 2018 | O&P ALMANAC

Each day,

507

people lose a limb.

PHOTO: Lizhi Pan, PhD

Approximately

movements that would take place if the hand and wrist were still whole. It then conveys that data to the prosthetic wrist and hand, which perform the relevant movements in a coordinated way and in real time—more closely resembling fluid, natural motion.” In preliminary testing, both able-bodied and amputee volunteers used the model-controlled interface to perform hand and wrist motions. The research team plans to enlist more transradial amputee volunteers for additional testing in performing activities of daily living. While much more work is needed before the technology becomes commercially available for clinical use, the researchers believe the technology may have applications not only in prosthetic devices but also in computer-interface devices for able-bodied individuals. The research has been published in a recent issue of IEEE Transactions on Neural Systems and Rehabilitation Engineering.

HAPPENINGS

Synthetic Nerves Could Help Restore Sensation Researchers from Stanford University and Seoul National University (SNU) have constructed an artificial sensory nerve system designed to sense touch, process information, and communicate with other nerves. The system is made of flexible organic components and could lead to the development of “reflexes” in prosthetic limbs, according to the research team. For the system to work, a “touch sensor” detects minuscule forces and sends signals through a second component, a flexible electronic neuron. Sensory signals from these components stimulate an artificial synaptic transistor modeled after human synapses. The system was engineered in such a way that it learned to recognize and react to sensory inputs based on the intensity and frequency of low-power signals, similar to a biological synapse. “Biological synapses can relay signals, and also store information to make simple decisions,” said Tae-Woo

Lee, PhD, who travelled from SNU to California to work collaboratively with the Stanford team led by Zhenan Bao, PhD. “The synaptic transistor performs these functions in the artificial nerve circuit.” The research team has tested the ability of the system to both generate reflexes and sense touch. In one test, researchers attached their artificial nerve to a cockroach leg and applied pressure to the touch sensor; the electronic neuron converted the sensor signal into digital signals relayed

PROSTHETICS PROGRESS

Analysts Predict Growth in U.S. Robotic Prosthetics Market The robotic prosthetics market in the United States is expected to grow at a compound annual growth rate of 5.51 percent over the next four years, according to a new report, “Robotic Prosthetics Market in the U.S., 2018-2022,” by global firm Research and Markets. A rising demand for customized prosthetics will be a key driver for market growth, according to the report. The number of amputation surgeries is increasing, the analysts said, and they predict more consumers will be fit with advanced devices such as robotic prosthetics, which are more

expensive than traditional devices. The report focuses on the present scenario and the growth prospects of the U.S. robotic prosthetics market.

through the synaptic transistor. These activities caused the cockroach leg to twitch. In another test, the artificial nerve was used successfully to differentiate Braille characters. While the technology is still in its infancy, according to the researchers, it could one day be used in conjunction with prostheses to restore sensation among amputees. “This artificial sensory nerve system is a step toward making skin-like sensory neural networks for all sorts of applications,” said Bao.

To calculate the market size, the report considered revenue generated from the sales of both upper- and lower-limb robotic prosthetics. Key vendors, including Blatchford, Fillauer, Össur, Ottobock, Steeper Group, and WillowWood, also are discussed. “The increasing number of technological advances and [research and development (R&D)] activities will be a key trend for this market growth,” noted one of the analysts. “Vendors are making significant investments in R&D and designing robotic prosthetics to fulfill the requirements of end users. Advanced robotic technologies improve the mobility of upper- and lower-limb amputees.” The study was conducted using a combination of primary and secondary information including inputs from key participants in the industry. O&P ALMANAC | JULY 2018

HAPPENINGS

AMPUTEE ATHLETICS

Adaptive Swimmers Take Part in First Swim Training and Clinic Hanger Clinic and Paceline Advanced Medical Solutions sponsored a First Swim Training and Clinic in Charlotte, North Carolina, at the Marion Diehl Recreation Center. More than 25 swim coaches, therapists, and O&P professionals participated in the two-hour classroom education, led by Chris Doerger, PT, CP. Therapists received 5.5 credits toward continuing education. The educational portion of the event, which focused on buoyancy, balance, adaptive equipment, and more, was followed by a two-hour First Swim Clinic, led by Mabio Costa, director of the Orthotic & Prosthetic Activities Foundation’s (OPAF’s) First Swim. Adaptive swimmers included individuals with limb loss, blindness, cerebral palsy, spinal cord injuries, and more. The event was supported by members of the NCAA Queens University Champion Swim Team.

JULY 2018 | O&P ALMANAC

O&P CYBERSECURITY

‘Insiders’ Often To Blame in Health-Care Data Breaches Approximately 1.13 million patient records were compromised in 110 health-care data breaches in the United States during the first quarter of 2018, according to the Protenus Breach Barometer. More than three quarters of the breaches resulted from a health-care insider “snooping on family members” (77 percent), according to the report. Other common reasons for a breach included “snooping on fellow co-workers” and “snooping on neighbors and celebrities,” according to the data. The largest health-care breach disclosed during the January-March 2018 time period resulted from an unauthorized third party gaining access to an Oklahomabased health-care organization’s network that stored billing information for nearly 280,000 patients. Patient information— including Medicaid numbers, healthcare provider names, dates of services,

and limited treatment information— may have been compromised. Last year, 5.6 million patient records were compromised during 477 total health-care breaches. Of those, 37 percent involved insiders, 37 percent involved hacking by outsiders, 16 percent involved loss or theft, and 10 percent were unknown.

THE LIGHTER SIDE

HAPPENINGS

APPS UPDATE

Apple To Allow Patients Greater Access to Electronic Health Records Apple has announced plans to allow third-party apps to access the health data stored in its Health app. Previously, Apple allowed patients of 500 hospitals and clinics to pull their health information from electronic health records (EHRs) into the Apple Health app. The change will allow those patients to move data from the Health app into third-party apps if developers have used the Apple Health Records application programming interface (API). The change will take effect this fall, when Apple releases iOS 12, according to the company. Health app users will be able to import medication data from Apple into Medisafe, a medication management

app. The Health Records API “will be an enabler of better health-care connectivity,” said Medisafe Founder and Chief Executive Officer Omri Shor. The private industry push to give patients more control over their data mirrors a similar push from federal agencies with initiatives like MyHealthEData and the 21st Century Cures Act, which both call on vendors to use open APIs for data exchange. Consumers using the app should verify that appropriate controls are in place. Apple has assured users their health data will be secure and that the company is not storing the health data on Apple servers. Instead, when a patient pulls data from an EHR, that

information is stored in an encrypted form directly on the patient's iPhone. When the patient sends data from the Health app to other apps, the data does not travel through Apple servers, according to the company.

AOPA ASSEMBLY PREVIEW

Two Options To Choose From:

Cruise Your Way to Vancouver

• September 19 – 26, 2018 – This option returns the morning that the Assembly begins. • September 15 – 22, 2018 – Exhibitors or those planning an extended vacation should choose this option, then plan to explore Vancouver September 22-24. Booth set-up begins on September 25.

Check one off the bucket list! A scenic Alaska cruise of the Inside Passage is the perfect way to complement your time in Vancouver. AOPA has partnered with AlaskaBySea, the Alaska cruise specialists, to bring you two Holland America cruise options that depart and return to Vancouver. Located right along the coast of British Columbia, the Inside Passage is the longest sheltered inland waterway in the world. Watch the water for orcas and humpback whales as you cruise the passage to the historic Alaskan ports of Juneau, Skagway, and Ketchikan.

The seven-night cruise departs from and returns to the Canada Place cruise terminal, mere blocks from the Vancouver Convention Center and Assembly hotels. Cabins begin at $949 per person, plus $215 tax, for double occupancy, with a free room upgrade and $50 onboard credit. The Assembly begins on Wednesday, September 26, at 8 a.m., with a full day of manufacturers’ workshops. The Exhibit Hall will open that evening. Exhibitors can begin setting up their booths on Tuesday, September 25. Visit AOPA’s website at www.aopanet.org for details.

Schedule for Seven-Day Cruise: Day 0: Depart at 4:30 p.m. Day 1: Scenic cruising the Inside Passage Day 2: Arrive in Juneau, Alaska, at 1 p.m.; depart at 10 p.m. Day 3: Arrive in Skagway, Alaska, at 7 a.m.; depart at 9 p.m. Day 4: Arrive in Glacier Bay at 7 a.m.; depart at 4 p.m. Day 5: Arrive in Ketchikan, Alaska, at 10 a.m.; depart at 6 p.m. Day 6: Scenic cruising the Inside Passage Day 7: Arrive in Vancouver at 7 a.m

O&P ALMANAC | JULY 2018

HAPPENINGS

RESEARCH ROUNDUP

O&P ADVOCACY

Vanderbilt Researchers Develop ‘Smart’ Ankle

Candidate for U.S. Senate Visits O&P Manufacturing Facility

JULY 2018 | O&P ALMANAC

Mitt Romney, a former governor of Massachusetts and the 2012 Republican presidential candidate, visited Ottobock HealthCare’s Manufacturing and Development Center in Salt Lake City in June. Romney, who is currently vying for a Utah Senate seat, toured the facility, spoke with employees, and viewed several products designed, tested, and manufactured on the premises. Tom Ryan and Bryant Jacobs, two veterans with transfermoral amputations, demonstrated some of the company’s prosthetic products and explained the differences between Ryan’s carbon-laminated socket and Jacobs’ osseointegrated prosthesis. “It was an honor to meet, host, and get to know Gov. Romney. He is a friend to those with limb loss, mobility challenges, and veterans,” said Scott Schneider, vice president of government, medical affairs, and future development. “I was also very impressed with Gov. Romney’s ability to grasp the function and parts of a prosthesis, [and] ask insightful questions of both our team members and the two veterans,” Schneider added. Schneider and Managing Director Brad Ruhl discussed with Romney some of the legislative challenges that, in some cases, make it difficult for patients to access technologically appropriate products. “As a potential

Gov. Mitt Romney with veterans Bryant Jacobs and Tom Ryan

future U.S. senator, his support to our mission is very important,” said Dave Wall, chief operating officer and vice president of global manufacturing. Romney addressed Ottobock employees after the tour, in a town hallstyle meeting, emphasizing the need to continue to provide products and services for veterans at centers associated with the U.S. Department of Veterans Affairs (VA) as well as vouchers for those who wish to seek care outside the VA. He also praised Ottobock employees, telling them, “I appreciate how fortunate you are, that you have not only a good job, but you also are able to do something that’s awfully Romney with Ottobock executives Lex Pearce, Scott good. … You make things Schneider, Sharon Baldauf, Brad Ruhl, and Dave Wall that really improve lives.”

PHOTOS: Ottobock

A new prosthetic ankle designed to anticipate movement and adjust the feet to different terrains, including challenging staircases, has been designed by researchers at Vanderbilt University. Led by Michael Goldfarb, PhD, a mechanical engineering professor and co-director of the Center for Rehabilitation Engineering and Assistive Technology, a research team has created a prosthetic ankle that features a tiny motor, actuator, sensors, and chip that work collaboratively to either conform to the surface the foot is contacting or remain stationary, depending on the needs of the user. An additional benefit of the ankle design is its ability to be worn with many types of shoes. “Our prosthetic ankle is intelligent, so you can wear a dress shoe, a running shoe, a flat—whatever you’d like—and the ankle adapts,” Goldfarb said. “You can walk up slopes, down slopes, up stairs, and down stairs, and the device figures out what you’re doing and functions the way it should.” The ankle is being tested by amputee Mike Sasser, who lost his left leg below the knee 10 years ago. Research team members are gathering feedback from the sensors in the device and making adjustments to the design based on the data accumulated as well as Sasser’s user experience. Team members also are interviewing potential users to seek input on design adaptations. Goldfarb’s team reportedly plans to commercialize the ankle within the next couple of years.

I N RTERAOK D T IUVC B I N U IGL TC W R O I TSHS P O DV EE R

Th i rrsaTc e s i Tbh le e c Pr ob s TThheaT T i ci nKvneeneT e d i T g e T yo ue r W mo or dl udl ’asrF b e xFTreonm Fa

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PEOPLE PEOPLE & & PLACES PLACES PROFESSIONALS

BUSINESSES

ANNOUNCEMENTS AND TRANSITIONS

Maureen Connelly has been awarded the 2018 Dale Yasukawa Scholarship from OPAF & The First Clinics. Connelly is expected to graduate from Northwestern University’s master’s program in prosthetics and orthotics in Maureen Connelly March 2019. She holds a bachelor’s of science engineering in chemical and biomolecular engineering degree from the University of Notre Dame. Connelly will receive a $1,000 scholarship to further her education by attending a national, regional, or local chapter or society meeting, or to put toward for educational purposes.

Coapt LLC has announced distribution agreements with Fillauer Europe AB and Orthopaedic Appliances Pty Ltd. (OAPL). These agreements will allow Coapt to bring its control systems for prosthetic arms to upper-limb amputees to Europe, Australia, and New Zealand. Under the terms of the agreements, Fillauer and OAPL will begin offering Coapt systems this fall. Coapt will retain responsibility for product development, domestic regulatory approval, quality management, and manufacturing while Fillauer and OAPL will be responsible for sales, marketing, customer support, and distribution activities.

Philipp Schulte-Noelle will join Ottobock’s management team as chief financial officer (CFO) under Chief Executive Officer (CEO) Oliver Scheel in August. His position completes the company’s Management Board under majority shareholder Hans Georg Näder. Scheel assumed the position of CEO in January and put together a new management team, with Andreas Goppelt as chief technology officer; Arne Jörn as a new chief operating officer; and Ralf Stuch as chief sales and marketing officer. “With the new CFO, we have put together a new management team within half a year, enabling us to work on our profitability and growth targets with a full line-up in the third quarter,” said Scheel. Jay Wendt has been promoted to the role of president, products and services, at Hanger Clinic. Wendt will lead Hanger’s Southern Prosthetic Supply (SPS), Accelerated Care Plus (ACP), and SureFit businesses. Wendt joined Hanger Clinic as west zone vice president in 2011 from his role as a division vice president of operations for Apria Healthcare Group. His previous experience includes progressive leadership roles in the health-care industry, including sales and marketing, after launching his early career as a respiratory therapist. He obtained his master of business administration from Baylor University, and his bachelor of science in health-care administration and associate of science in respiratory therapy from Texas State University in San Marcos.

Kenney Orthopedics Prosthetics and Orthotics, with eight offices in Kentucky and four in Indiana, has acquired a 13th facility in Monroe, North Carolina. Rob Ito, CPO, will serve as managing partner and provider. Myomo Inc. has announced that CMS has published a favorable preliminary decision regarding the company’s application for Health-Care Common Procedure Coding System (HCPCS) L codes. Myomo had filed an application in December 2017 to have CMS establish two new Level II HCPCS codes to describe “microprocessorcontrolled, custom-fabricated, upper-extremity braces.” If the decision is made permanent, the codes will become effective on Jan. 1, 2019. The assignment of unique L codes, if followed by appropriate payment terms, would offer greater access to the MyoPro for Medicare beneficiaries.

IN MEMORIAM Virgil William Faulkner, CPO(E), a pioneer in the orthotics and prosthetics profession, passed away at age 83 on May 31, 2018, in Melbourne, Florida. Faulkner served in the U.S. Marine Corps from 1954 to 1958. He was a certified prosthetist and orthotist for more than 40 years. He also was a co-patentee of CAD/CAM for prosthetic sockets.

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REIMBURSEMENT PAGE

By DEVON BERNARD

Lessons Learned From the TPE Program Initial results indicate lower denial rates, with room for improvement in O&P claim submissions

Editor’s Note—Readers of Reimbursement Page are eligible to earn two CE credits. After reading this column, simply scan the QR code or use the link on page 20 to take the Reimbursement Page quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.

CREDITS

TARGET

TPE

Program PROBE

EDUCATION

N LATE 2017, the durable medical equipment Medicare administrative contractors (DME MACs) switched to a new auditing and medical review format. They moved away from widespread prepayment and postpayment reviews, and instead focused their efforts on select prepayment claims, implementing a new program: the Target, Probe, and Educate (TPE) program. Noridian, the DME MAC for Jurisdiction D, is the first DME MAC to release the results of its first round of TPE audits, for the period spanning from October 2017 to December 2017. The other DME MACs will be releasing their results in the near future. This month’s Reimbursement Page reviews the preliminary findings from Noridian and analyzes ongoing reasons for improper payment rates or denials.

TPE Program Review

The TPE program was introduced as a way to reduce the current backlog of appeals by reducing claim denials and educating suppliers and providers. The program focuses its audit efforts on only a select set of high-risk claims and providers/suppliers, and encourages resolution of appeals earlier in the process. Currently, the TPE program focuses solely on claims related to the provision of certain ankle-foot orthoses (AFOs), knee-ankle-foot orthoses (KAFOs), lumbosacral orthoses (LSOs), thoracolumbosacral orthoses (TLSOs), and diabetic shoes. The TPE program consists of potentially three rounds of prepayment reviews, and each round involves between 20 and 40 claims. If the results 18

JULY 2018 | O&P ALMANAC

E! QU IZ M EARN

BUSINESS CE

CREDITS P.20

of the first round of reviews are deemed acceptable, the provider/supplier receives a notice that it will be removed from the audit pool for a period of one year. If the results are not acceptable, the provider/supplier will be scheduled for a personalized education session with the appropriate DME MAC claims review department. This session will focus on common errors (such as missing or incomplete documentation, illegible signatures, missing medical necessity documentation, etc.) and strategies to improve the error rates. After the personalized education session is complete, a second round of prepayment reviews will take place, about six to eight weeks after the first education session. If the results are still not acceptable after the second round of reviews and subsequent education sessions are complete, a third round may take place. During each round of prepayment review, providers have the opportunity to be removed from the audit pool if their results are considered acceptable. However, if after three rounds a supplier still has a high error rate, it may be referred to CMS for additional action.

AFO and KAFO Results

During the three-month period, claims were reviewed for walking boots described by codes L4360, L4361, L4386, and L4387. The results indicated an improper payment rate of 19 percent, which is a drastic improvement over previous improper payment rates. For example, previous prepayment audits for L4360 and L4361 showed improper payment rates of 98 percent and 64 percent, respectively.

REIMBURSEMENT PAGE

Reasons for the improper payment rate or denials included the following: improper detailed written order (DWO) on file, medical records not authenticated, same or similar brace on file, and no documentation to support the need for replacement (lost, stolen, or irreparably damaged). These denial reasons are fairly consistent in all the TPE results. For those claims that resulted in denials due to medical records not being authenticated, the denials usually occurred because the documentation provided in response to the additional documentation request was not signed or the signature by the ordering/referring physician was illegible. This problem also may have been caused by the provider or supplier who created the documentation, such as an O&P facility’s staff or a physical therapist. Medicare requires that anyone ordering or documenting the medical necessity for items/services must be identifiable; and as such each provider/supplier must sign each entry in the patient’s medical record. Three types of signatures are considered valid for authentication: • Stamped signature: This is only permissible if the person using the stamp has a disability that renders him or her unable to handwrite a signature or use an electronic signature. • Electronic signature: The DME MACs have stated that in order for an electronic signature to be considered valid, the signature should be accompanied with a statement (“electronically signed by,” “authenticated by,” or “approved by”) that shows the signature was applied electronically; the electronic signature doesn’t need to be manually applied (using a stylus), but it could be applied by entering a unique identification number that automatically places a “typed” signature to the document. • Handwritten legible signature. A handwritten signature, or any mark or signature by an individual to signify knowledge, approval, acceptance, or obligation, is acceptable.

When reviewing your records for a TPE audit or during the education component of the TPE program, if you realize a document is missing a signature or the signature has been deemed illegible or invalid, there are two common and acceptable ways you can authenticate the signature and/or the medical record entry. First, you may use a signature log—a key or a list of typed or printed names, along with the corresponding signature. The signature log should include the printed name of the physician, provider, or supplier and the full signature and/ or the initials as they would appear on a signed document. It is not necessary to include the physician’s or provider’s credentials with your signature log, but the DME MACs and Medicare do encourage this practice so consider including them. Second, you may choose to use an attestation statement—a statement that allows for the signatory to attest to the authenticity of his or her signature and/ or the entry made in the medical record. To be valid, the attestation statement must be signed and dated by the person who originally made the medical record entry or who originally signed the document in question, and it must contain enough information to clearly identify the patient. A sample attestation statement is available in the Supplier Manuals and in the Program Integrity Manual on the Medicare website. If the validity of an electronic signature is called into question, you may use a version of the attestation statement,

or you may ask the physician’s office to provide a statement indicating that it has established procedures in place that allow only the physician to attach his or her signature or make changes to a document.

Knee Orthosis Results

During the three-month period during which claims for knee orthoses were reviewed via the TPE program, results for codes L1810, L1812, L1832, L1833, and L1843 indicated an improper payment rate of 77 percent. While this may seem high, it is lower than previous improper payment rates. For example, previous prepayment audits for L1832 and L1833 showed improper payment rates of 99 percent and 88 percent, respectively. Reasons for improper payment rates or denials included improper DWO on file, documentation doesn’t support coverage criteria, documentation was not received with additional documentation request (ADR), and documentation did not support the custom-fit criteria. We will examine the last reason, “documentation doesn’t support the custom-fit criteria.” According to policy, there is no difference in the function or design of the off-the-shelf (OTS) version and the custom-fit version of a particular orthosis; the difference in the item comes in the amount of modifications required to fit it to a particular patient. In other words, the difference is that a custom-fit item has been substantially trimmed, bent, molded, assembled, or otherwise modified by a person with expertise, to fit one specific patient only. O&P ALMANAC | JULY 2018

REIMBURSEMENT PAGE

Documenting just the medical necessity is no longer sufficient; when providing a custom-fit item, you also must document the modifications or, more importantly, the specific modifications that were made to an orthosis to achieve a unique and custom fit. When documenting modifications, it is important to demonstrate that the modifications go beyond simply cutting and bending; you must document that they were more substantial and could not be done by anyone else. So be sure to document exactly what was modified—for example, how much of the orthosis was trimmed or bent and where these modifications were made. Also, account for the time it took to achieve each modification as well as what tools were used for each modification. Any last-minute modifications made at the time of the final fitting and delivery also should be documented in detail. And be sure to document who made all of the modifications and the delivery, as the policy clearly states that it must be carried out by a certified orthotist or someone with specialized training. Remember that, according to Medicare interpretations, a certified fitter would not be considered eligible to deliver and fit a custom-fit orthosis.

Spinal Orthosis Results

During the three-month period, claims were reviewed for spinal orthoses described by codes L0627, L0630, L0631, L0637, L0642, L0643, L0648, and L0650. The results indicated an improper payment rate of 34 percent. The previous improper payment rate for L0648 was 70 percent, and for L0650, 58 percent. The reasons for the improper payment rate or denials included same or similar item on file, no documentation to support the need for replacement (lost, stolen, or irreparably damaged), documentation doesn’t support coverage criteria, and documentation was not received with ADR. In the May 2018 O&P Almanac Reimbursement Page article, we discussed the need to document when an item is lost, stolen, or irreparably damaged, so we will look at not submitting documentation in a timely manner. When you are a subject of a TPE 20

JULY 2018 | O&P ALMANAC

Therapeutic Shoe Results

review, you will be sent an ADR, and you will be given 45 days to respond to that ADR. If you don’t respond within that timeframe, you will receive an automatic denial for the claim(s) in question. If you are not passing a TPE review, or any other audit, because you failed to respond to an ADR, most likely one of two things occurred: The DME MACs didn’t have your proper address on file or you simply forgot about the ADR until it was too late. To avoid these possible scenarios, verify your correspondence address, as listed on your Medicare application, and make sure it matches your existing location’s address. If the addresses don’t match, update the address with Medicare—this goes for all of your satellite offices as well. If you don’t routinely visit your satellite offices, consider having all correspondence sent to your main location. Also, make sure you have a set of protocols in place outlining who is responsible for opening, sorting, and delivering the mail. This person should be able to identify the ADR requests and should know who is in charge of handling the ADR requests. Keep in mind that an automatic denial is not all that can happen when forgetting to submit documentation to an ADR request. The DME MAC could report you to the National Supplier Clearinghouse for violation of the Supplier Standards, which could lead to the suspension of your Medicare billing number.

During the three-month period, the DME MAC reviewed claims for diabetic shoes described by code A5500. The results indicated an improper payment rate of 13 percent—a drastic improvement over previous improper payment rates. For example, previous prepayment audits for A5500 showed an improper payment rate of 88 percent. The reasons for the improper payment rate or denials included: documentation doesn’t support coverage criteria, documentation/signature was illegible, beneficiary already received the items billed, and claims submitted with improper patient information. The Therapeutic Shoe Policy is very clear when it states that a patient may only receive one pair of shoes per calendar year (January-December), and that any additional shoes are denied as noncovered. If you are aware that a patient has already received one pair of shoes and you are submitting a claim for a second pair of shoes, if it is possible that the patient’s secondary insurance will cover the items, be sure to submit the claim with the GY modifier. Also, with the introduction of the new Medicare ID cards and the new Medicare Beneficiary Identifier, be sure you are double-checking the patient’s information prior to submitting your claims. If you are mindful of the denial reasons covered in this month’s Reimbursement Page and you are selected for a TPE (or any other audit), you may be able to pass the first round with an acceptable rate. Devon Bernard is AOPA’s assistant director of coding and reimbursement services, education, and programming. Reach him at dbernard@AOPAnet.org. Take advantage of the opportunity to earn two CE credits today! Take the quiz by scanning the QR code or visit bit.ly/OPalmanacQuiz. Earn CE credits accepted by certifying boards:

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This Just In

Official Recognition AOPA applauds the withdrawal of the ‘Dear Physician’ letter and works to ensure O&P notes are recognized

N FEBRUARY 2018, AOPA reported that the provision from the Medicare O&P Improvement Act recognizing the orthotist’s and prosthetist’s notes as part of the medical record was signed into law as part of the Bipartisan Budget Act of 2018, or the continuing resolution to fund the government. Section 50402 of the Act required that Section 1834(h) of the Social Security Act be amended to include the following paragraph:

(5) DOCUMENTATION CREATED BY ORTHOTISTS AND PROSTHETISTS.— For purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by eligible professionals described in Section 1848(k)(3)(B). As with any new law, there were several unanswered questions, primarily how Section 50402 would be interpreted and implemented by the durable medical equipment Medicare administrative contractors (DME MACs). The DME MACs had stated on several occasions that they could not 22

JULY 2018 | O&P ALMANAC

The letter from Alec Alexander, CMS’s deputy administrator and director of program integrity, is a clear assertion of CMS’s commitment to acknowledge immediate implementation of the new statutory provisions in Section 50402, accepting the clinical notes of the orthotist and prosthetist as part of the individual’s medical record. implement the new law without direct input and guidance from CMS. AOPA and its lobbying team have been hard at work pressing CMS from all levels, including a recent consultation with Trump administration officials at the Office of Management and Budget, and a letter to Alec

This Just In

Alexander, CMS’s deputy administrator and director of program integrity. Within the last few months AOPA has seen the results of these meetings and lobbying efforts. First, the DME MACs released a revised version of the controversial August 2011 “Dear Physician” letter on lower-limb prosthetics. The revised version included this statement regarding the new law: “CMS is in the process of considering any program changes that may be necessary as a result of this legislation. Thus, this article is being retired pending instructions from CMS.” While the retirement of the Dear Physician letter does not mean that the DME MACs will no longer require physician documentation to support claims for artificial limbs, it is a clear indication that they acknowledge and understand that the provisions of the original Dear Physician letter are no longer consistent with the law and therefore can no longer be used as the sole justification for denying a Medicare claim.

Second, AOPA received a positive response from Alexander. In his response letter, Alexander noted that CMS “has issued instructions to the [DME MACs] to implement Section 50402 immediately.” Alexander’s letter is a clear assertion of CMS’s commitment to acknowledge immediate implementation of the new statutory provisions in Section 50402, accepting the clinical notes of the orthotist and

prosthetist as part of the individual’s medical record as to “determining the reasonableness and medical necessity of orthotics and prosthetics,” e.g., functional levels; identification of broken, damaged parts and their repair; and identifying components in a category included in a physician approved detailed written order. A copy of Alexander’s letter is available on AOPA’s website at bit.ly/ AlexLetter. AOPA will continue to keep members informed of any new developments or published guidelines from the DME MACs. Until the DME MACs release or provide O&P suppliers with guidance on how claims will be reviewed and adjudicated under the new law, AOPA recommends that members continue to work with their referral sources to receive as much supporting documentation as possible, and continue their documentation as well. AOPA also suggests that members consider including a copy of the letter with all claims they file.

AOPA Celebrates Health-Care Compliance & Ethics Week November 4-10, 2018

• Demonstrate your company’s commitment to ethical business practices • Create awareness of the Code of Conduct, relevant laws, and regulations • Provide your staff with recognition for training completion, compliance and ethics successes • Reinforcement—of the culture of compliance for which your organization strives. AOPA has developed several tools and resources to assist you. Visit our dedicated web page for tools, resources and more:

bit.ly/aopaethics

O&P ALMANAC | JULY 2018

COVER STORY

Senior Surge Clinicians share patient-care strategies for aging baby boomers and elderly patients By CHRISTINE UMBRELL

JULY 2018 | O&P ALMANAC

COVER STORY

NEED TO KNOW MM The aging of the approximately 74 million baby boomers in the United States has led to a growing senior patient population at O&P facilities. These patients often present with more co-morbidities than their younger counterparts. MM Many senior patients have secondary medical conditions when they undergo an amputation, and present with skin challenges or joint degradation that will need to be considered during prosthetic fittings. MM For some older patients, their prosthesis is their “good” leg, particularly in individuals who have neuropathy, wounds, or arthritis, so attention to componentry selection and proper prosthetic fit is extremely important.

MM Clinicians should follow the latest research related to fall risks and the senior population. Recent studies by the RAND Corp. and the Mayo Clinic have demonstrated the value of microprocessor knees in preventing falls, but payors may not reimburse for these types of devices for patients who are not K3 ambulators. MM A team approach to senior patient care can be beneficial. Working closely with the patient, his or her family, the prescribing physician, and other members of the health-care team in an interdisciplinary approach can lead to a well-thought-out care plan and optimal clinical results.

MM On the orthotics side, some seniors experience a natural decrease in strength and proprioception as they age, as well as issues related to foot drop. For these patients, it’s important to select orthotic materials carefully, and avoid devices that may be too heavy.

&P FACILITIES are increasingly being frequented by baby boomers—a

demographic that comprises approximately 74 million people in the United States, according to the U.S. Census Bureau. With the aging of this demographic, loosely defined as Americans born between 1946 and 1964, comes an influx of new O&P patients. Today’s orthotists and prosthetists will need to prepare for a spike in the senior population and tailor their patient-care skills to ensure optimal results.

A Magnification of Health Challenges

While older patients pose a number of challenges to O&P clinicians, due to an increased likelihood of co-morbidities, skin challenges, and joint degradation, solving some of their problems has become easier, says Jason Wening, MS, CPO, FAAOP, residency director at Scheck & Siress. “We have access to ways of designing sockets and technology for knees and feet that make it so much easier to find solutions,” he says. “We now have the tools to get people up and walking in a comfortable and safe manner, which wouldn’t have been possible 20 years ago.”

Prosthetics technology continually evolves, with new and upgraded devices offering benefits to the senior population. For example, hydraulic ankles “result in a lot more stability” for patients, and may help instill confidence in some senior patients, says Kevin Carroll, MS, CP, FAAOP, vice president of prosthetics for Hanger. “It takes a lot of skill on behalf of the prosthetist to fit older adults,” explains Carroll. “We’re dealing with skin that’s atrophied and is fragile. But there are new technologies, such as breathable gel liners, that help.” O&P ALMANAC | JULY 2018

COVER STORY

But challenges arise because more Medicare patients now have secondary conditions when they get an amputation, according to Wening. “Their amputations may be the smallest part of their global health problems.” Diabetic and vascular care have improved so much that, by the time seniors require an amputation, they are older, weaker, and are experiencing more wound and vision complications, he says. “And we’re seeing more people who are amputees who have had a stroke beforehand.” Prosthetists should recognize that, for some older patients, “their prosthesis is their ‘good leg,’” adds Wening, particularly in patients who have neuropathy, wounds, or arthritis. “So, it’s important that the prosthesis be in good condition.”

Jason Wening, MS, CPO, FAAOP

In addition, many seniors require second amputations not long after their first one—which can be problematic because amputation involves multiple surgeries, and a long, drawn-out rehabilitation process, notes Wening. “Even before getting fit with their first prosthesis, they’re getting the other limb amputated,” he says. And if older vascular patients become bilateral above-knee amputees, they may no longer be able to ambulate using prostheses. “Walking on prostheses is more than some bilateral AK patients can handle.” Like Wening, Tom Martin, MS, CP, BOCO, of Ability Prosthetics and Orthotics in Hanover, Pennsylvania, also is seeing an uptick in “unhealthier” older patients who are diabetic or have dysvascular complications—and who sometimes wait longer than they should to see a clinician. “The older patients are a lower functional level, typically K2, usually with an 26

JULY 2018 | O&P ALMANAC

Tom Martin, MS, CP, BOCO

ambulatory aid,” he says. “Our goal is to get them up and walking as soon as possible to prevent other issues,” but setbacks may arise stemming from neuropathy and skin conditions. Another hurdle, according to Rodney Coleman, CP, of Wright & Filippis, is that more senior patients are presenting with co-morbidities. “Instead of just losing limbs to diabetes or peripheral vascular disease, they also are presenting with heart problems, dementia, and Alzheimer’s,” says Coleman. While senior prosthetics patients are on the rise, orthotists also are seeing an influx of older patients. Taffy E. Bowman, CPO, a clinician at Ability Prosthetics and Orthotics in its Exton and Limerick, Pennsylvania, offices, notes that many older patients have been referred by physical therapists, podiatrists, neurologists, orthopedists, vascular specialists, and physical medicine and rehab specialists. Most are fit “with ankle-foot orthoses or knee braces to help with gait function or to decrease pain, or a brace to improve their quality of life for some who are not candidates for surgery,” she says. Bowman notes that what she considers the “senior population” is comprising a wider range of patients. “I see a lot of individuals with co-morbidities in their late 50s,” she says. She attributes some of these earlier health concerns to “the American diet,” which has resulted in many individuals contracting high blood pressure, diabetes, and other difficult conditions.

A Team Approach

Given the challenges associated with treating senior patients who may have, or could develop, secondary health conditions, it’s essential for orthotists

and prosthetists to engage in a team approach to care. First and foremost, Coleman recommends getting the patient’s family involved—particularly for prosthetic patients. “You may need to identify a helpful family member or close friend to provide assistance with donning and doffing, as well as care of the prosthesis. They need a solid support network at home,” he says. Coleman suggests conducting a home assessment to understand the obstacles at home, such as the entryway, stairs, and other barriers. Beyond involving family, Coleman suggests working closely with the prescribing physician, surgeon, and family members “to make sure that what you’re doing [in terms of prosthetic care] isn’t going to negatively impact” intervention by others on the care team, he says.

Taffy E. Bowman, CP

Wening also suggests that O&P clinicians engage with other members of the health-care team, in an interdisciplinary approach, to have honest discussions and set goals. “There are a lot of decision points along the way, leading up to an amputation, where other health-care professionals” assist patients through making those decisions, he says. “It’s never just one health-care professional who’s making an outcome successful,” explains Wening. “Two dozen people may be involved, with all different knowledge and skill sets. These people should be talking to each other. We also need to better understand the influence that each health-care provider can have on the final outcome.” For example, quality of amputation, quality of prosthesis, and quality of therapy all have an effect on patient outcome.

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COVER STORY

“As we take ourselves out of our ‘O&P silo’ and start thinking about continuum of care,” suggests Wening, “we need to have legitimate conversations about individuals’ goals for the rest of their lives. We need to consider the global goals for a patient and his or her family. We need to discuss, ‘Are we going down the right path—the path we thought we would be going down? Or should we reconsider?’ We all have a story of a patient postamputation who says, ‘I wish I had done this two years earlier.’” And these discussions should be initiated by O&P professionals as integral parts of the care team. While not warranted in all cases, earlier amputations could lead to prolonged mobility. “If a patient wants to go to Disneyland and be able to walk around while they’re still in generally good cognitive health,” perhaps an earlier amputation would allow for improved mobility, Wening suggests.

Supporting Orthotics Patients

On the orthotics side of the business, John Galonek, CPO, of Wright & Filippis, remarks that he is seeing more patients in rehab hospitals, versus 10 or 15 years ago. “Now more than ever, we are seeing more cases of foot drop, and tripping and falling,” he says. As patients age, there is a “natural decrease in strength and 28

JULY 2018 | O&P ALMANAC

proprioception, and some seniors develop balance issues, as well as increased problems with clearance and swing in foot drop,” explains Galonek. He points to “weight” of materials as an important variable in determining appropriate bracing for this population. “With the advent of carbon fiber, [senior patients] have been able to try some lighter devices that are more user-friendly,” he says. “We try to steer patients toward carbon-fiber, floor-reaction-style devices with greater tibial control.”

John Galonek, CPO

As in prosthetics, optimal senior care for orthotics patients requires an assessment of patients’ living situations, says Bowman. She suggests talking to patients’ physical therapists (PTs) or other health-care professionals, with patient permission, to get a feel for a patient’s abilities—psychosocially as well as physically. Bowman notes that it’s important to know whether a patient is living

in a skilled nursing facility versus a home environment, and who will be helping the patient manage his or her care. “Consider what the goal is for the device we’re providing, and what we can expect in terms of compliance and consistent wear,” she says. Even with caretaker buy-in and assistance, one of the biggest challenges in treating older orthotic patients is the occasional resistance to change, says Galonek. “Change is hard, so you have to have a lot of dialogue” with these patients. “You need to make sure everyone’s on the same page, and make sure patients are comfortable with the direction you’re moving.” He suggests having samples ready, making use of “fit kits,” and letting patients try on new devices first. “Give them something tangible to set the stage” for wearing the new orthosis, he suggests. And it may be necessary to make concessions. “Patients may not be comfortable with the device you think is most appropriate,” Galonek says. “You may have to talk it through, or provide a device that’s a little lighter than you’d like to make sure they use the device at all.”

Attention to Fall Prevention

Aside from providing standard orthotic and prosthetic care, today’s clinicians also should be educated and understand the fall risks that pose a threat to all senior patients. While simple groundlevel falls can be relatively harmless to young people, they can lead to severe injury and death in elderly individuals, according to research from the University of Rochester Medical Study. But orthoses and prostheses can play a significant role in reducing falls. For amputees, recent studies carried out by the RAND Corp. and at the Mayo Clinic have demonstrated the value of microprocessor knees in preventing falls (see sidebar on page 29). But despite published data pointing to benefits for Level K2 amputees who were transitioned to microprocessor knees, payors do not often reimburse for these components for K2 ambulators.

COVER STORY

Research Demonstrates Microprocessor Knees Can Prevent Falls Two important research studies published last year pointed to the risk of falls for seniors and the efficacy of microprocessor technology in preventing falls. The AOPAcommissioned RAND Corp. study on “Economic Value of Advanced Transfemoral Prosthetics” demonstrated that microprocessorcontrolled knees (MPKs) result in fewer falls. Soeren Mattke, MD, presented the findings of the published research during a press event last October, explaining that MPKs are associated with improvements in physical function and reductions in falls and osteoarthritis, and that the economic benefits are in line with commonly accepted criteria for value for money by U.S. payors. RAND looked at data for patients using microprocessor-controlled prostheses compared to patients using nonmicroprocessor-controlled prostheses. Ultimately, the RAND analysts were able to quantify several benefits of microprocessor technology. “The big impact is with respect to falls,” said Mattke. “Amputees have a much lower probability of falling and injuring themselves with the microprocessor-controlled knee than the noncontrolled knee. And then that translates into follow-up on cost and quality of life for the patients,” he said. In addition, microprocessor-controlled devices generate value by offering more stable gait. “So, you get a lower probability of osteoarthritis and the quadrilateral knee because you just walk,” Mattke said. In fact, the study found almost an 80 percent relative risk reduction in injurious falls—“not just falls where you trip and catch yourself, but falls

where you really have an injury, either a minor injury or a major injury, that requires hospital admission,” said Mattke. “As a consequence, you also have about an 80 percent risk reduction in fall-related deaths that is basically a consequence of these major injuries of falling. These are pretty impressive effects.” Kenton Kaufman, PhD, shared additional information about the risks of falls for amputees during the October AOPA press event, when he explained the findings of a recent study by the Mayo Clinic published in Prosthetics and Orthotics International. The study, titled “Direct Medical Costs of Accidental Falls for Adults With Transfemoral Amputations,” was a retrospective cohort study of adults who underwent transfemoral amputations between 2000 and 2014, and found benefits for Level K2 amputees who were transitioned to MPKs. “Even if an amputee [without microprocessor technology] avoids death due to a fall, he or she may suffer very serious consequences from a fall-related injury,” said Kaufman. “The average additional cost in the six

months following a fall can be substantial. The cost for individuals requiring an emergency department visit is about $18,000. For patients who had to be hospitalized, this extra expense is over $25,000” or even more, as these dollar amounts are thought to be underestimates of the actual total costs. Kaufman and his colleagues identified a significant reduction in falls when individuals at Level K2 were converted from nonMPKs to the more advanced devices—accompanied by additional health benefits. “The individuals were more active on the microprocessor knee. They went from 60 percent of the time sitting on the nonmicroprocessor knee to 50 percent on the microprocessor knee,” said Kaufman. “And then when they went back to the nonmicroprocessor knee, they actually had less confidence so the amount of time sitting was 65 percent.” The researchers quantified the quality of study participants’ gait and found that the quality of their gait more than doubled on the MPK. “And not surprisingly, they reported an improved quality of life when using the microprocessor knee,” Kaufman said.

O&P ALMANAC | JULY 2018

COVER STORY

“We’ve known for a long time that amputees fall more frequently than age-matched nonamputees,” says Wening. “It’s not if you’re going to fall, but when.” O&P professionals can help minimize the situations where patients might fall—and microprocessor knees can aid in achieving that goal. Prosthetists should seriously consider microprocessor technology for patients who might qualify.

“A lot of the K2 transfemoral population would benefit from MPK [microprocessor-controlled knee] technology,” says Martin. “The stumble recovery feature in MPKs can prevent the knee from giving out” and inspire more confidence among patients. “Once a transfemoral amputee falls once, they’ll never forget—and that can hinder trust in their prosthesis.”

Coleman also believes MPKs prevent falls, and he is happy to fit elderly patients with the devices if they meet the qualifications. He notes that it’s important to work closely with the patient’s therapist “so the patient is as strong as possible to control the advanced prosthesis.”

Rodney Coleman, CP

TIPS

for Treating Senior Patients

O&P clinicians experienced in treating senior patients offer the following suggestions to ensure positive patient interactions and optimal clinical results: Be present. “Health care is a chaotic place right now, with purchasing pressures, reimbursement pressures, and family pressures. But when you’re with a patient, forget about all of that, and listen to them,” says Jason Wening, MS, CPO, FAAOP, residency director at Scheck & Siress. “Don’t try to solve the problem before listening to them.”

Explain thoroughly. Expect some seniors to ask the same questions over and over again. Just be patient and “over-explain” the care plan and how the device will work, says Tom Martin, MS, CP, BOCO, of Ability Prosthetics and Orthotics.

Encourage open communication. “Some of these patients may have health issues that make it harder to communicate—for example, being deaf,” says Kevin Carroll, MS, CP, FAAOP, vice president of prosthetics for Hanger. “But that doesn’t mean their cognition is compromised. Find a way to communicate.”

Stay positive. Particularly with patients who have diabetes, “we work hard to get them back on their feet,” says Carroll. But “we have to be positive, to get patients motivated and inspired to get them moving—that’s what we do. It’s all about a good patient experience.”

JULY 2018 | O&P ALMANAC

Wening shares the story of an 80-year-old patient he was able to transition to a microprocessor knee. “He had been wearing a prosthesis for 50 years, and was still working as an auto mechanic,” says Wening. He came in to Scheck & Siress wearing a 12-year-old prosthesis. “He was walking as a K2 and balancing as a K2, but [that’s because] he had developed bad habits.” Due to the patient’s active lifestyle—and the fact that he was still working on cars—Wening decided to “take a risk and put him in a new test socket with a microprocessor knee.” Within an hour of the first fitting appointment, the patient had learned how stable the knee was and how to use it properly. After a few weeks, the patient returned to the facility and was tested again with a well-fitting socket and the new knee. “He tested as a K3 ambulator, cleanly, and today he’s walking with the microprocessor knee.” Carroll also believes that many patients may benefit from microprocessor knees. “We need to make sure we’re not pigeonholing a patient based on his or her age,” says Carroll. He cites the example of a 91-year-old patient who is still extremely mobile and is walking well with a microprocessor knee. “He has total confidence in himself and in the technology,” says Carroll, encouraging other clinicians to steer clear of making decisions based on age, and instead “look at the abilities.”

COVER STORY

Bowman notes that falls have become even more of a problem as the rate of obesity and co-morbidities has risen, leading to joint degradation and premature deterioration of knees, hips, backs, and ankles. She advocates for increased physician education in understanding patients’ fall risk levels. “Some doctors may overlook gait dysfunction in patients and fail to refer them for O&P care,” she says. Some physicians see patients seated in exam rooms, and may not be aware of gait issues—especially if patients don’t voice any concerns. Many of these patients would benefit from orthotic intervention, explains Bowman. Carroll adds that proper wear instructions also may contribute to a reduction in falls. “The prosthesis has to be put on correctly to make sure there isn’t a fall risk,” he says. “Oftentimes, we recommend occupational therapy for donning and doffing training, and upper extremity strengthening.”

Kevin Carroll, MS, CP, FAAOP

More Frequent Patient Visits

Because older patients’ health may change more rapidly than younger patients, Carroll advocates for seeing senior patients every three months at a minimum. “The more often we see them, the sooner we can see any signs of decline,” he notes. During these visits, O&P clinicians may notice health issues that should be addressed by other health-care providers. “A lot of times, we see patients at a different level and with more frequency than physicians,” explains Carroll. “We watch them walk, go up and down stairs, and move. If we notice they have shortness of breath, then we need to recommend

they see their doctor and suggest a visit to their cardiologist.” In making these types of referrals, “we save lives unbeknownst to ourselves.” Some patients may need to be encouraged to visit dermatologists for skin issues. Still others may have osteoporosis, and “get weaker with age, with more brittle bones,” adds Carroll. “We recommend bone density tests. And we may send them to a physical therapist to strengthen their muscles and [for] balancing training.” Carroll also notes that patients should be encouraged to see clinicians on a regular basis—even if they travel part of the year. He notes the growing population of “snowbirds”—people who live up north during the warmer months but migrate south for the winter. These patients may need to see O&P clinicians in both locations. “We want to make sure the prosthetic device we give them in Florida will still be appropriate up North,” says Carroll. “They may have different activities” in each location.

Providing Expert Care

With a growing number of Americans entering their senior years, there’s a lot of space for O&P professionals “to really define ourselves as the experts. We need to not just look at the residual limb, but look at the whole person, and find the best solution for that person,” says Wening.

And, just as with younger O&P patients, relationships are key to ensuring optimal patient care. “What I love most about treating this population is developing relationships with them,” says Coleman. “A lot of them have great life stories. Sometimes I have a patient who needs a small adjustment to his prosthesis, but he stays for 45 minutes because he hasn’t had anyone to talk to for a week. That’s good patient care.” Bowman also warns against rushing the appointment. “This age group appreciates being heard and understood. Part of the appointment time should be spent meeting that expectation,” she explains. “That’s good patient care, and it’s good business sense” because patients may share their opinions of their O&P patientcare experiences with their physicians and other referral sources. Taking the time to listen to patients, treat the whole person, work closely with other health-care professionals, and ensure patients’ needs are met will be key to treating the senior population in the future. With roughly 10,000 baby boomers turning 65 each day, O&P clinicians will need to embrace this approach sooner, rather than later. Christine Umbrell is a contributing writer and editorial/production associate for O&P Almanac. Reach her at cumbrell@contentcommunicators.com. O&P ALMANAC | JULY 2018

By MEGHAN HOLOHAN

Shared Experiences Many O&P patients benefit from role models and guidance provided via peer mentoring programs

After Matthew Brewer (right) lost both his legs above the knee, he became friends with Cameron Clapp (left) and realized he could still live a full and active life. The two surf together near Huntington Beach in California where Brewer lives.

NEED TO KNOW • Peer-support programs that match new amputees with experienced prosthesis users can lead to better outcomes for people who have lost a limb. Many O&P facilities point patients toward organized peer support programs, or implement their own initiatives, to aid patients in their recovery. • While the provision of role models and encouragement from other amputees are important facets of peer mentoring programs, they also are beneficial in preparing new prosthesis users for the sometimes arduous road to mobility.

JULY 2018 | O&P ALMANAC

• Amputees who volunteer to serve as peer mentors often get as much out of the experience as they give, and enjoy sharing both their struggles and success stories with others. • In addition to pointing patients toward one-on-one peer support programs, some clinicians also note that walking schools and camps can serve important purposes, offering people with limb loss a safe place to practice skills among people who look like them.

PHOTO: Matthew Brewer

• Many clinicians have found that peer support programs make a noticeable impact on all parties involved, and propose that patients participate in such programs as an essential part of rehabilitation.

• O&P professionals can turn to the Amputee Coalition as one resource for patients who would benefit from working with a peer mentor, or for patients interested in serving as mentors. The organization offers a Certified Peer Visitor program that certifies individuals who have undergone a background check and participated in training.

PHOTO: Hanger Clinic Inc.

FTER BEING SOBER FOR five months, Matthew Brewer relapsed and overdosed on heroin in September 2014. For 18 hours he was passed out on his bathroom floor, laying awkwardly on his legs. By the time paramedics arrived, he had developed compartment syndrome, a build-up of pressure in the muscles that can result in permanent damage if not treated. Doctors were unable to release the pressure, and Brewer had to undergo a bilateral above-knee amputation. Becoming an amputee made him feel insecure, isolated, scared, and depressed. “I felt like an outcast,” he says. While having his legs amputated helped him become sober for good, Brewer, now 43, felt too awkward trying to walk with prosthetic legs—so he didn’t. “I have no knees. I couldn’t even get comfortable in my stubbies,” he says. “I felt like a penguin and couldn’t get used to being that short.” Brewer thought he would never walk again. For more than a year, he relied on a wheelchair to move and depended on friends and family for help. He simply accepted that he would never be truly independent. But then something changed: As he grappled with his feelings of denial and isolation, he heard about the Bilateral Above-Knee Amputee Bootcamp run by Hanger Clinic, and he decided to take a risk and attend. As soon as he arrived in Oklahoma City in 2016, he saw a man with a bilateral aboveknee amputation and one arm. That man, Cameron Clapp, immediately befriended Brewer, changing his life. “Seeing him get through the airport on his own independently was all the motivation I needed,” Brewer recalls. Taking part in the Bilateral AboveKnee Amputee Bootcamp gave Brewer more than a friend; he also gained a peer mentor, who provided insight, friendship, and strength as he navigated life as an amputee. “That peer support they gave me … was so awesome. It inspired me,” he says. Brewer’s experience echoes what experts have long suspected: Peersupport programs often lead to better outcomes for people who have lost a

Pedro Pimenta (far left), Cameron Clapp (second from left), Matthew Brewer (fourth from left), and others have benefitted from their friendship and help other recent amputees by volunteering as peer mentors. limb. Several O&P facilities and organizations host or guide new amputees toward participating in peer support programs, which can have a noticeable positive impact on people experiencing limb loss. “Peer support is crucial to well-being,” says George Gondo, director of research and grants at the Amputee Coalition of America. “A lot of emerging evidence shows that somebody’s emotional wellbeing, their depression, [and] anxiety levels have an impact on their satisfaction with a prosthetic device.”

Setting an Example

When Brewer first travelled to Oklahoma City, he met Clapp as well as several other amputees that offered him a glimpse at a future that was brighter than he had previously imagined. One of those role models was Pedro Pimenta, the national coordinator for Hanger Clinic’s AMPOWER peer support program.

Pimenta, a quadruple amputee, lost his limbs after contracting spinal meningitis at age 18. He first became involved in peer support activities after meeting Clapp. At the time, Clapp “was living a life I didn’t even know was possible,” says Pimenta. “When I finally had an opportunity to meet him, I didn’t touch my wheelchair once.” Pimenta realized how transformative it was to meet Clapp and felt inspired to share what he learned with people who have also experienced limb loss or limb difference—thus, his decision to join the AMPOWER initiative. In his current role, he helps organize the more than 1,100 peer support visitors trained by Hanger Clinic spread throughout the United States across many of Hanger Clinic’s 800 facilities. These are people who have experienced amputation or limb difference and who are trained to provide friendship and support to people who are just learning how to live without a limb. O&P ALMANAC | JULY 2018

COVER STORY

Soon after Matthew Brewer had his legs amputated, he believed he would never walk or be independent again. Today, he regularly goes to the gym and runs and swims in races.

JULY 2018 | O&P ALMANAC

Improving Outcomes

Some individuals have noted that participants in peer support programs seem happier and better adjusted to living with their prosthetic device. Empirical evidence aside, research is emerging demonstrating the positive impact of peer support on patient outcomes. “Peer support is very valuable and effective,” says Mark Hopkins, PT, CPO, MBA, chief executive office and president at Dankmeyer Prosthetics and Orthotics Inc. “Most of the studies are focused on quality of life. There are reports of people with limb loss [who had peer support] increasing their life satisfaction and ability to engage in the community.” Dankmeyer Inc. works closely with the Amputee Coalition’s peer support group to provide its clients with CPVs. There are 300 amputee support groups registered with the Amputee Coalition that can have access to CPVs. While most outcomes are ultimately positive, the Amputee Coalition tries to prepare people for a long, challenging journey.

“It is a very emotional process, and we try to stress how recovery is very unique and nobody recovers the same way,” Osborne-Simpson says. “It is very comforting to people that request a visit.” Gondo says that much of the research into peer support examines its effect on people with mental health and addiction. “There are some studies that have looked at peer support in the limb loss community and have shown some benefit,” he says. People who take part in some type of peer support program experience an improved quality of life and report less depression and anxiety, according to Gondo. This translates into people scoring higher on a patient activation measure, which means they experience fewer complications and co-morbidities—and can serve as a good financial investment, too. “How someone scores on patient activation measures translates to health savings,” Gondo explains. He thinks that many health-care systems hesitate to fund peer visitor programs because there are only a handful of studies looking at their effectiveness for people with limb loss. “The amount of evidence is a little bit lower than most other areas of health care,” he says. “Within health care, everyone is looking for value outcomes. If you can’t demonstrate you are going to positively impact patient outcomes,” then there is little interest in funding such programs, he says. Fortunately, the Amputee Coalition recently received funds to study the impact of peer support on people with limb loss and limb difference, according to Gondo.

PHOTO: Matthew Brewer

“The first step to physical and psychological rehab is acceptance. When you lose a limb, it is very visual. It is an identity shock. It is out of the blue. Something is wrong or something is different,” Pimenta says. “If you are surrounding yourself with people who have been through what you have been through … you get to share a bond with them.” Hanger Clinic patients can ask their clinicians to organize a visit or fill out a request form on the AMPOWER website. But Hanger isn’t the only organization that realizes the value of peer support. Since 1993, the Amputee Coalition has hosted a Certified Peer Visitor (CPV) program, which serves people with limb loss or limb difference throughout the country. The organization has trained 1,500 people—either individuals who are at least 12 months postamputation, or caregivers of individuals living with limb loss—to visit and support people with limb loss and limb difference; currently, there are 700 active volunteers. Volunteers

undergo a background check and eight hours of training, where they learn how to recognize recovery and support people experiencing it. After completing the program, volunteers can start making visits when requested. Tonya Osborne-Simpson, director of peer support for the Amputee Coalition’s peer visitor program, tries matching people based on age, gender, and type of amputation. While peer visitors believe they are helping others, she has noticed that volunteering helps them, too. Amputees who submit an application for the program are usually in the last step of recovery, says Osborne-Simpson. “They made it through, and they are ready to give back,” she says. While the friendship helps people experiencing new limb loss adjust to their lives, it also serves as an important part of the healing process. “Support is a very important pillar of rehabilitation,” Pimenta said. “You can certainly help change a person’s perspective of themselves just by being there.”

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Encouraging Participation

Many clinicians have found that peer support programs have a noticeable impact on all parties involved, and propose participation in such programs as an essential part of rehabilitation. While the clinician’s contribution to rehabilitation can never be overstated, says Hopkins, “it is really powerful for someone to see another person like them after limb loss.” He explains that peer mentors can demonstrate how they are living their life, via “a new normal.” From that experience, new amputees “see there is another day—a brighter day. As someone who does not have limb loss, I can’t show them that,” Hopkins notes.

At the Bilateral Above-Knee Amputee Bootcamp, Matthew Brewer (right) met Pedro Pimenta (left) and realized how important peer support was to his recovery.

JULY 2018 | O&P ALMANAC

PHOTOS: Matthew Brewer

Individuals who volunteer to serve as peer visitors or mentors also note the healing power of peer interactions. “They get more out of the visit, more than they give,” says Osborne-Simpson. “They get to sit and talk about recovery and the relationship with their prosthetist and finding a good support group, and they get to answer those tough questions.” In addition to pointing patients toward one-on-one peer support programs, some clinicians also note that walking schools and camps can serve important purposes, offering people with limb loss a safe place to practice skills among people who look just like them. Dankmeyer Inc., for example, hosts an Amputee Walking School that provides individuals with

limb loss a chance to learn how to walk or improve their gait. “We may have 50 people in a big gym—that is a lot of people at various levels of ability and various levels of limb loss,” Hopkins says. Participants “really enjoy the social part of it.” While providing social support and a comfortable place to practice walking remains an essential part of the school, Hopkins says the program also When Matthew Brewer first attended promotes physical activity— the Bilateral Above-Knee Amputee which can help participants Bootcamp, he joined about 50 other avoid co-morbidities, such as people with above-knee amputations on obesity and type 2 diabetes, and their stubbies at a mall in Oklahoma City. leads to better overall outcomes. There he started feeling less self-con“We are very focused on this scious and realized he could walk again. particular program, and using the peer visitor [program] to encourage mobility or walking,” he says. Hanger Clinic’s annual Bilateral surf camp with Clapp and participates Above-Knee Amputee Bootcamp in in swimming and running events close Oklahoma City is designed to help to his home in Huntington Beach. He attendees improve their mobility and serves as a mentor to other people build strong community bonds. The experiencing limb loss. experiences participants go through “It is incredibly inspiring to me are incredible, Pimenta says. Many to be able to mentor new amputees. participants arrive in wheelchairs, It is rewarding knowing I am giving sometimes before they are fully healed. someone advice that I know helped But by the time they leave, many me immensely, and being able to share are walking, having benefitted from that advice and being able to connect the “kickstart” provided by the peer to a human being in a similar situasupport. And some never use a wheeltion,” he says. Brewer is returning to school to chair again. “The transformation is study computer maintenance techamazing,” Pimenta says. Gondo also has noticed that nology, and he continues to participate participants in activities that convene in at least one event a month with groups of individuals with limb loss the limb loss community. “It gives me are “overjoyed to be around several something to look forward to, and that hundred people who are missing a gives me motivation to work harder at limb. They may know one or two achieving my goals,” he says. people without a limb, [but] they have Those involved with peer mentonever been in an environment with so ring programs echo what Brewer many people who are like them,” he has experienced, and strongly assert says. “It is really empowering.” that peer support programs benefit everyone involved. Helping others is “a two-way road,” Pimenta says. Motivated To Give Back Many individuals who take part in peer “Volunteers are also getting inspired and accepting themselves even mentoring programs have stories of further. When you are helping, you success to share with others. Brewer, are being helped as well.” for example, no longer uses a wheelchair. In 2017, he started walking with microprocessor knees, and his life is Meghan Holohan is a contributing now active and full. He has gone to writer to O&P Almanac.

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THE EDUCATIONAL SESSIONS PLANNED FOR THE 2018 AOPA NATIONAL ASSEMBLY WILL FEATURE CUTTING-EDGE RESEARCH, DISCUSSIONS OF NEW TECHNOLOGIES, PRACTICAL BUSINESS STRATEGIES, AND MUCH MORE

NEED TO KNOW • The 2018 AOPA National Assembly in Vancouver will feature educational sessions focusing on the latest O&P technologies, research, and clinical and business trends. • Clinical sessions will focus heavily on evidence-based research and offer a variety of information in hands-on sessions. Attendees can expect to sharpen their skills and come away with a greater understanding of the clinical aspect of the O&P profession. • Business education sessions will feature topics geared toward business owners and managers, practitioners, and distributors. Some sessions qualify for credits toward the O&P Business Management Certificate.

JULY 2018 | O&P ALMANAC

• Attendees also may take part in sessions in a dedicated pedorthic track, designed to educate participants about the many changes occurring in the pedorthics space and the latest information about new technologies, scanning trends, and more. • Technical education programming will touch on several recent advances geared toward technicians and fabricating clinicians and will include discussions regarding 3-D printing, advanced fabrication techniques, dynamic bracing, and scanning and CAD software.

S YOU FINALIZE YOUR PLANS for the AOPA National Assembly

in Vancouver, you are likely thinking about which educational sessions you should attend. Organizers from the planning committees for the business education, clinical orthotics and prosthetics education, pedorthic education, and technical education sessions have carefully organized programming to provide insights into industry trends, the latest technological advances, best practices, and research. “The AOPA meetings are among the most interesting on the conference circuit because the program offers a diversity of themes, professions, and subjects at an equally high quality across those themes and subjects,” says Silvia Raschke, PhD, who co-chairs the Clinical Session Planning Committee and is a project lead and principal investigator at the Centre for Rehabilitation Engineering and Technology that Enables (CREATE) in Burnaby, British Columbia. This year’s programming has been developed to educate attendees with the latest information related to all facets of running an O&P business—from providing optimal clinical care, to leveraging the latest technologies, to running a profitable O&P business.

Can’t-Miss Clinical Sessions

While all of the clinical sessions will This year’s clinical sessions focus provide valuable information, several heavily on evidence-based research sessions stand out. that can help practitioners improve The clinical education track will the quality of care and introduce kick off with a preconference workinnovation at their own O&P practices. shop on Tuesday, September 25, The sessions were chosen based on titled, “Contemporary Overview of their ability to “present high-quality Lower-Limb Prosthetics Impression information or knowledge that allows Techniques,” led by Mark Muller, [participants] to go home and apply it MS, CPO, FAAOP; and Jesse Spellen, to their clinical practices in a way that CP(C); and David Moe, CP(C). This both benefits their patients and makes hands-on course will teach particibusiness sense,” says Raschke. The pants to improve their skills in several education will feature many hands-on impression-taking techniques. sessions to allow attendees to sharpen The annual Thranhardt Lecture their technical skills; most will deliver Series will be presented at 8 a.m. on applied research. Thursday, September 27. “My focus is on the Tiffany Graham, MSPO, application end of knowlCPO, LPO, and Brian Kaluf, BSE, CP, FAAOP, have been edge development and selected as the award-wininnovation. This is where the rubber hits the road, ning speakers for this year’s and you see if what has series. Graham will discuss been tested in the lab actucranial remodeling orthoses for infants with deformaally works in the real-life Silvia Raschke, PhD setting,” says Raschke. “We tion plagiocephaly, and now know transformative innovation Kaluf will present the findings from a flourishes best in an interdisciplinary, comparison study of microprocessor diverse environment.” and energy-storing prosthetic ankles.

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Research-oriented O&P professionals won’t want to miss the Thursday morning session, “Outcomes and Evidence-Based Practice in O&P: How Are You Documenting Value in Your Clinic and Using It to Improve Reimbursement?” Several speakers who have extensive experience in documenting outcomes in O&P facilities—including James Campbell, PhD, CO, FAAOP; Brian Hafner, PhD; Andreas Hahn, PhD, MSc; Kenton Kaufman, PhD, PE; Russell Lundstrom, MS; Brittany Pousett, CP(C), MSc; and Scott Sabolich, CP—will convene at 10 a.m. and share strategies for using clinical outcomes data to improve reimbursement. The session titled, “Update on the Evidence for Benefits of Microprocessor-Controlled Knees in Limited Community Ambulators: Review of the Literature, Results of Current Studies, and Future Research Projects,” will take place at 1:30 p.m. Thursday afternoon and will relay new research on microprocessor-controlled prosthetic knees for people with above-knee amputations. Speakers will include Stephan Domayer, MD, PhD; Andreas Hahn, PhD; Andreas Kannenberg, MD (GER), PhD; Kenton Kaufman, PhD, PE; and Sara Morgan, CPO, PhD. O&P ALMANAC | JULY 2018

“Integrating Outcome Measures To Improve Patient Care,” scheduled to begin at 3:15 p.m. on Thursday, will offer a series of free papers that focus on the importance of incorporating outcomes measures into clinical decision making. Presenters will share 11 different papers tied to this topic, including a paper titled, “Matching Individuals Based on Comorbid Health Reveals Improved Function for Above-Knee Prosthesis Users With Microprocessor Knee Technology,” by Shane Wurdeman, PhD, CP, FAAOP, and a paper titled, “Predictors of Clinical Improvement After LowerLimb Prosthetic Fittings,” from Russell Lundstrom, MS. Friday, September 28, will feature a session on “Technology for Geriatrics” at 10 a.m. The symposium will give an overview of the current and future advances that will help clinicians treat older patient populations. Speakers include Cleveland Barnett, PhD; Charlie Guan; Andreas Kannenberg, MD, PhD; Homayoon Kazerooni, PhD, MSME; Don Nixdorf, DC; and Josh White, DPM, CPed. Attendees won’t want to miss a Friday 1:30 p.m. session, “Multidisciplinary Panel on

JULY 2018 | O&P ALMANAC

Business Best Practices Rehabilitation of the Paretic Arm.” This session will After sharpening their examine current clinical clinical skills, attendees may understandings of how spaswant to learn more about best practices in business—to ticity impacts and challenges get ideas for integrating new people who have cerebral systems and procedures into palsy. David Coleman, CPO; Eileen Levis their O&P companies. Skills Brandon Green, DO, BOCP; learned in these sessions will Alexander Shin, MD; Steven help clinicians and business managers Wolf, PhD, PT, FAPTA; and Alan H. provide optimal treatment while runWeintraub, MD, will share their expertise and theories. ning efficient and profitable businesses. These are just a few of the hot “Our goals for the sessions are to topics to be deliberated during clinprovide the tools necessary for owners, managers, and practitioners to make ical sessions at the Assembly. “There informed decisions in running their will be a good cross section of topics practices and providing quality patient covered and strong speakers,” promcare,” says Eileen Levis, co-owner of ises Raschke. Orthologix, a former member of the AOPA Board of Directors, and chair of the Business Session Planning Committee. Some business sessions qualify for credit toward the O&P Business Management Certificate— similar to nondegree continuing education certificates offered by universities. To receive a certificate, attendees must complete the core modules and one elective, for a total of eight courses. These courses focus heavily on finance, management, sales and marketing, and operations. “Our Business Certificate Program is a great way for key members of your staff to attain recognition and expertise that adds value to your practice,” says Levis.

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R EMBE SEPT

26-2

2018

Assembly attendees have the opportunity to take three courses toward their certificate on the afternoon of Wednesday, September 26, beginning at 1 p.m. Sessions include “Basic Financial Accounting—How To Read a Financial Statement,” presented by Adam Herman, CPA; this session will cover balance sheets, cash flow statements, income statements, and statements of shareholders equity. The “Overhead Reduction Strategies” session will be presented by Kathleen DeLawrence and is designed to help businesses “go lean” in an ever-challenging business environment. The final session, “Operating Performance Benchmarking Survey: What It Can Do for You” 42

JULY 2018 | O&P ALMANAC

they are not navigating these waters alone,” Levis says. A new session, “The Impact of Professional Women in O&P,” featuring moderator Teri Kuffel, JD, along with Cathy Carter; Arlene Gillis, CP, LPO, MEd, FAAOP; Pam Lupo, CO; Ann Moss; and Robin Seabrook, will focus on women’s roles in the profession. This Friday afternoon session complements the Women’s Breakfast, which debuted two years ago. “This is a great opportunity to hear from professionals about the challenges and opportunities facing women in our field and the great contributions they are making,” Levis says.

is being planned and developed by the Operating Performance Report Task Force chaired by Jeffrey Brandt, CPO, joined by Mark Brady, Mark Ford, Elizabeth Ginzel, CPO, Michael Oros, CPO, FAAOP, Jim Weber, MBA, and Michael Becher, and will teach attendees how to use AOPA’s financial clinical benchmarking survey to improve their businesses’ functioning. The business track also will offer sessions focusing on “Compliance in a Changing World,” beginning at 1:30 p.m. on Thursday, September 27. Three separate sessions led by Carol Albaugh, LPTA, and Bill Wilson, CPIA, will look at strategies Pedorthic Programming for protecting businesses The Vancouver educational from cyberattacks, protoprogramming also will procols for clinical practice, vide plenty of information and the latest informaand research centering on pedorthic topics. A big part tion about the Health of the pedorthic track will Insurance Portability and feature presentations that Accountability Act. “We want every attendee Dennis Janisse, CPed come under the heading of “Top 10 Insights for Making to leave with an underand Keeping Your Pedorthic Practice standing of regulatory issues and Successful,” according to Dennis compliance. We want every attendee Janisse, CPed, president and chief to hear from the ‘specialists’ on billing, executive officer of National Pedorthic marketing, [and] process improvement Service Inc., and chair of the Pedorthic tips,” Levis says. Session Planning Committee. “There The “Prosthetists’ Notes” session are many changes taking place in from David McGill, slated for 3:15 PM the pedorthic world and practices on Thursday, September 27, will at this time, and our program will examine the recent changes recoghelp folks navigate some of these nizing O&P clinicians’ notes as part new challenges—new understanding, of the official record, and will discuss technology, knowledge, and business what that means for prosthetists who practices.” are recording vital information about Attendees can anticipate learning their patients. more about new technologies, such as “We ultimately hope that every “use of scanning and great technology to participant leaves the Assembly supply a variety of foot orthoses quickly knowing that we as a group at AOPA are focused on ‘them’ at every level and and cost effectively,” Janisse says.

Janisse says the pedorthic sessions will help O&P professionals prepare their practices for transition. “People feel that things are changing,” he says. “Yes, they are, but depending on how you look at those changes, they can be very exciting and rewarding for the practitioners, practices, and ultimately the patients we serve and care for on a daily basis.”

process. “Advanced Lamination Techniques in Orthotic Fabrication” with Jacob Keough, CO, at 11 a.m. will provide tips for laminating lower-extremity orthotic devices. This session is designed to offer a greater understanding of composite materials in designs while showing proper model preparation, layups material selection, and finishing methods. “Each year we are bringing Time To Get Technical the most up-to-date content Expect plenty of cuttingthat is available,” Mattear says. edge presentations in the “We strive to make sure the technical track at the 2018 content is relevant and specific AOPA National Assembly. in nature. The common goal “The technical program is to have a review from the … is consistently striving attendees that is complemento provide content that Brad Mattear, the technician or fabritary and [to know] that they LO, CPA, CFo are leaving with more info cating practitioner can than they arrived with.” take back to the lab and use almost During “Advanced Prosthetic immediately. We feel that traditional Fabrication Techniques” on Thursday fabrication techniques, combined afternoon, Caroline Sylvestre will with cutting-edge informatics, such share the latest innovations in prosas 3-D printing, are what bring a vast and dynamic attendee [group] thetic fabrication techniques to help to our sessions,” says Brad Mattear, clinicians provide optimal devices. LO, CPA, CFo, managing director at In the “Future Tech—Emerging Nabtesco & Proteor in USA and head Technologies in O&P” session with of the Technical Session Planning Steve Hill, CO, BOCO, at 2:30 p.m. on Committee. Thursday afternoon, participants will In “A Modular Approach to learn about smart materials, flexible Dynamic Bracing,” scheduled for glass, brain implants, gene therapy, 10 a.m. Thursday, September 27, and the latest information about 3-D attendees will learn from Scott printing. “This year we continue our Wimberley, CTPO, CPA, and Greg series on ‘Future Tech’ and enhance Mattson, CTPO, about dynamic [the program] with new sessions bracing and design principles, with specifically geared toward 3-D printing additional information about casting, for technicians and assistants,” modification, and the fabrication explains Mattear. “Attendees will also get exposure to new fabricating techniques in orthotics, something

that commonly gets overshadowed by prosthetics. … We are very excited to see new process management taking place.” Mattear hopes that technical sessions will encourage technicians to seek out further training to advance their skills. “I am a huge advocate for technicians and always strive to advance the very personal task of becoming certified. I strongly encourage each noncertified technician out there to take the next step and obtain your credential [from the American Board for Certification in Orthotics, Prosthetics, and Pedorthics (ABC)] as a certified technician,” he says. “In the same breath, I ask that central fabrication facilities take the next step and become a certified central fabrication facility through ABC.” All of the sessions planned for the 2018 National Assembly have been designed to educate attendees on the latest O&P technologies, best practices, processes, and research. Participants will return home from Vancouver with knowledge of the latest technological advances and research as well as heightened business acumen. “There should be something for everyone that they can take home and continue to think about long after the meeting is over,” Raschke says. Meghan Holohan is a contributing writer to O&P Almanac. O&P ALMANAC | JULY 2018

COMPLIANCE CORNER

By DEVON BERNARD

Secondary Status Which entity should be billed when other payors are primary to Medicare?

Editor’s Note: Readers of Compliance Corner are now eligible to earn two CE credits. After reading this column, simply scan the QR code or use the link on page 46 to take the Compliance Corner quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.

CREDITS

CREDITS P.46

KEY COMPONENT OF A viable and effective compliance plan is the creation of written policies and procedures. Your policies and procedures should address areas you have identified as prone to potential fraud or abuse. This would include such areas as claims development and the claims submission process, or improper coding and submission of claims to the proper payor. Policies and procedures do not have to be complex; they can be simple statements such as: “We attempt to verify any payors that may be primary to Medicare and only bill Medicare when appropriate.” To help ensure compliance in properly identifying payors primary to Medicare and in submitting claims to the proper payor, this month’s Compliance Corner examines the programs that would render Medicare to secondary payor status. There are six programs that will always render Medicare to secondary payor status, meaning that a patient’s alternative insurance must be billed first.

The first and most common program that is primary to Medicare is the working aged program. In this program, an individual has become entitled to Medicare benefits, based on age, but has not yet retired. For patients to be considered working aged, they must be at least 65 years of age and enrolled in their employer’s group health plan (EGHP); the employer must have at least 20 employees. The EGHP also may cover the patient’s spouse; in that case, the spouse is considered “working aged,” even if he or she is currently retired. For the purpose of the working aged provision, the term “spouse” is defined as “a person whose marriage is valid in the jurisdiction in which it was performed, including one of the 50 states, the District of Columbia, or a U.S. territory or a foreign country, so long as that marriage would also be recognized by a U.S. jurisdiction.”

JULY 2018 | O&P ALMANAC

EARN

BUSINESS CE

The Working Aged

E! QU IZ M

In addition, any time an employer, insurer, third-party administrator, or group health plan has a more inclusive definition of spouse, it may assume primary payment responsibility for the individual in question; and if the individual is reported as a spouse, Medicare will pay accordingly. If the patient has a retirement plan through his or her employer and is 65 or older, the retirement plan will always be secondary to Medicare. If the patient chooses not to be covered by the EGHP and wants Medicare as his or her primary insurer, he or she cannot also receive benefits from the EGHP; it may only be one or the other.

Workers’ Compensation

Another common scenario involves workers’ compensation (WC) claims, claims that are the result of an injury that occurred on the job. In most cases, Medicare will not make payments on

COMPLIANCE CORNER

a WC claim, but there are times when you may send a WC claim to Medicare. If you don’t agree to accept the WC payment as your payment in full, and your state allows you to collect your full charge, you may submit the WC claim to Medicare for secondary payment. In addition, when dealing with a patient who has a WC claim, you may come across a set-aside arrangement or a set-aside payment. A set-aside arrangement is “an administrative mechanism used to allocate a portion of a settlement, judgment, or award for future medical and/or future prescription drug expenses.” In situations where a set-aside arrangement has been established, Medicare may not pay for any future services until the administrator of the arrangement or the patient provides evidence that payments were spent appropriately. This means that all of the funds were disbursed and only used for services related to the injury or illness/disease. Once the set-aside

amount is exhausted and accurately accounted for, Medicare will pay primary for future Medicare-covered medical and/or prescription drug expenses related to the injury or illness/disease.

No-Fault and Liability Insurance

The next two programs—no-fault insurance and liability insurance—involve coverage by an insurance company, typically involving some type of accident that does not occur at work. No-fault insurance, which also includes personnel protection and medical expense coverage, covers expenses due to injuries that occurred on the insured’s property, or in the use of the insured’s vehicle, regardless of who is responsible for the accident. Liability insurance applies when someone is found to be at fault for causing an injury and payment is based on the policyholder’s legal liability for injury. The two most common types of liability insurance are auto and malpractice insurance.

Similar to workers’ compensation claims, no-fault and liability insurance claims may involve set-aside arrangements, and those funds must be appropriately depleted before Medicare will make payments. In addition, with liability insurance, no-fault insurance, and, to a certain degree, workers’ compensation insurance claims, you have the ability to seek a conditional payment. Medicare may make a primary payment when there is evidence that the primary payor will not or cannot pay the claim promptly. Medicare defines a “prompt” manner to be within 120 days. When you believe or can demonstrate that the primary payor will not pay the claim in a prompt manner, you may submit the claim to Medicare and Medicare will make a conditional payment. However, if it is determined that someone else should have paid first or you eventually receive payment from the primary insurer, you must refund Medicare.

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Chart Your Course for Financial Success Today at www.aopa-survey.com. Invest the time to participate in the 2018 OPC Survey. It will reap rewards. O&P ALMANAC | JULY 2018

COMPLIANCE CORNER

When seeking a conditional payment, you may not seek primary payment from two insurers at the same time. If you choose to seek a conditional payment from Medicare, you must withdraw any claims you have with the primary insurer and/or drop any liens you may have placed on the beneficiary.

Disabled Beneficiaries

Medicare provides benefits and coverage to anyone who has a permanent disability, regardless of their age. If someone is receiving Medicare benefits because of a disability, Medicare will usually be primary. However, it is possible for Medicare to become the secondary payor when certain criteria are met. First, the patient must be under 65, receiving Medicare benefits solely because of a disability, and have other health-care coverage under a large group health plan (LGHP). The coverage from the LGHP may be through the patient’s current employment or the current employment of a family member—parent, spouse, or another qualifying relative. An LGHP is slightly different than an EGHP used in conjunction with the working aged provision. In order for a group health plan to be considered an LGHP, there must be at least 100 people employed by the sponsoring company, or, in the case of a plan that covers multiple employers, at least one employer in the group must have at least 100 employees. For example, if Mr. Smith is covered by an LGHP and he has a disabled child, who has qualified for Medicare due to his disability, the LGHP would be billed as the primary and Medicare as the secondary for any of the child’s medical expenses—including expenses not related to the disability.

End-Stage Renal Disease

If a patient is diagnosed with end-stage renal disease (ESRD), he or she is entitled to receive Medicare benefits, even if he or she is younger than 65. If ESRD is the only reason a patient has Medicare benefits, and he or she is covered by an EGHP, then Medicare will be secondary to the EGHP. The ESRD provision is a little more complicated than some of the other 46

JULY 2018 | O&P ALMANAC

provisions because there are certain situations when Medicare will retain its primary payor status when a patient has ESRD. Medicare will be secondary for ESRD patients for a total of 30 months, which is called the “ESRD coordination period.” The coordination period begins when the patient first becomes eligible for Medicare benefits. After the coordination period ends, Medicare will become the primary payor. If the patient is under 65 and has Medicare benefits solely because of ESRD, the patient also is entitled to all Medicare benefit categories, not just those related to the treatment of the ESRD; however, his or her entitlement to Medicare benefits will expire 12 months after his or her last dialysis treatment or 36 months after a successful kidney treatment. So, if you have a patient that has Medicare coverage due to ESRD, it would be wise to routinely check his or her coverage or status, because who is primary and secondary can shift, and he or she may no longer have Medicare coverage.

Next Steps

Knowing which programs may render Medicare a secondary payor is only the first step. Be sure you have procedures in place to identify primary payors. To assist in this task, Medicare has created a lengthy but comprehensive

questionnaire that can be used by your office. If you don’t want to use the questionnaire, you may create one of your own or you may rely on the Benefits Coordination & Recovery Center (BCRC), the contractor responsible for maintaining and reporting insurance coverage for Medicare patients. The BCRC can be reached Monday through Friday, 8 a.m. to 8 p.m. Eastern Time, at 855/798-2627. If you call the BCRC, a representative will be able to inform you whether a patient has an insurer primary to Medicare but cannot provide you with any other information; you must obtain all other information from the patient. You also will need to communicate the findings to the proper staff in your office, as the U.S. Office of the Inspector General has stated that a lack of communication between different departments within a supplier can easily result in the supplier filing incorrect or improper claims. Make sure you have protocols in place to ensure proper communication between all departments, even if you are a small facility. If one person handles intake and collects the patients’ insurance information and a different person does the billing, make sure they communicate effectively. Knowing which entity to bill can get complicated when Medicare is a secondary payor—but doing your homework, communicating with your patients about their status, and understanding the different scenarios that render Medicare to secondary status will help prepare you for success and equitable reimbursement. Devon Bernard is AOPA’s assistant director of coding and reimbursement services, education, and programming. Reach him at dbernard@AOPAnet.org. Take advantage of the opportunity to earn two CE credits today! Take the quiz by scanning the QR code or visit bit.ly/OPalmanacQuiz. Earn CE credits accepted by certifying boards:

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PRINCIPAL INVESTIGATOR

A Quest for the Next Kenton R. Kaufman, PhD, PE, shares his experiences as a musculoskeletal research professor at the Mayo Clinic and makes a call to action

Kenton Kaufman, PhD, PE

For 2018, O&P Almanac is introducing 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.

JULY 2018 | O&P ALMANAC

ENTON R. KAUFMAN, PhD, PE,

likes to explore new territories. When he first got married, he and his wife set a goal of travelling to all 50 states—and they met that goal five years ago. “We greatly enjoyed getting acquainted with the geographical and ethnic diversity that exists throughout the nation,” he says. “We have also traveled to six continents.” So, it comes as no surprise that Kaufman has explored many facets of O&P-related science and has made several important discoveries during the course of his career at the Mayo Clinic. It’s been nearly three decades since he first dove into the O&P research arena, and his long list of publications and contributions over the past years is well-known both within and outside the O&P profession. Kaufman—whose current titles include W. Hall Wendel Jr. Musculoskeletal Research Professor; professor of biomedical engineering; director of the Motion Analysis Laboratory; and consultant in the Departments of Orthopedic Surgery, Physiology, and Biomedical Engineering at the Mayo Clinic—was first drawn to the O&P profession “by the fact that our

efforts can make significant improvements in the function and mobility of the patients we treat,” he says.

Setting Off on the O&P Research Path

Kaufman has spent the past 22 years working with a team at the Mayo Clinic to advance orthotic and prosthetic science. His initial involvement in the O&P arena began in 1989, when he began working on the first microprocessor-controlled stance-control orthosis. In 1992, his team received funding from the National Institutes of Health (NIH) for that effort. This class of products “offered substantial improvements over previous designs, which were rejected at rates of 60 to 80 percent,” he explains. The work received sustained funding from NIH until 2002, when Kaufman’s team concluded a clinical trial and issued three patents that were licensed. Through a sponsored research agreement, the SensorWalk—of which Kaufman is co-inventor—came into the marketplace in 2008. Kaufman also dedicated a substantial amount of research time to the area of microprocessor-controlled knees (MPKs), beginning in the early

PRINCIPAL INVESTIGATOR

2000s. “When this research began, MPKs were an unproven, experimental technology,” he recalls. “As a result of this work, medical policy changed in 2007 to read, ‘Microprocessor prosthetic knees are medically necessary for qualified transfemoral amputees.’” The research resulted in a substantial positive change in available care to patients with amputations, according to Kaufman. “This work is particularly poignant now that our country is seeing an increasing number of traumatic war-related above-knee amputations,” he says. More recently, Kaufman has focused on longitudinal effects of prosthetic care. “We have a unique resource at Mayo Clinic called the Rochester Epidemiology Project (REP),” he says. The REP has been in existence for more than 50 years and contains the health records of all individuals living in Southeastern Minnesota, which enables the Mayo Clinic to investigate the long-term effects of prosthetic care. Regarding the REP project, Kaufman has focused primarily on transfemoral amputees (TFAs). His studies have resulted in several key findings: “We have found that only about 25 percent of TFAs receive a prosthesis,” he says. “We have also determined that the cost of a fall resulting in hospitalization is $26,000.” In addition, his team has quantified the effect of prosthetic care on cardiovascular health.

in falls, spent less time sitting, and increased their activity level. Subjects also reported significantly better ambulation, improved appearance, and greater utility. This clinical trial demonstrated that individuals with TFA and K2 mobility clearly benefit from an MPK.” One interesting finding from the study was a reduction in falls that occurred while the subjects engaged in more physical activity, “which resulted in increased subject satisfaction. The increase in activity resulted in a greater exposure to fall risk, but that risk was moderated by the advanced technology,” says Kaufman.

Ongoing Explorations

Kaufman also is working on an investigation into a unique rehabilitation technique to prevent falls for individuals with limb loss and limb preservation procedures. “We have developed a training program that re-creates the physics of a fall in a safe learning environment,” he says. “This program is scalable so that the postural disturbances begin with gentle disturbances and progress to more energetic disturbances.” The program consists of six sessions over two weeks, and the researchers have been able to demonstrate “that we are able to substantially alter an individual’s response to postural perturbations that result in falls,” notes Kaufman. On top of research responsibilities, Kaufman is heavily involved in educating the next generation of researchers,

One of Kaufman’s most recent projects is a comparative effectiveness study, comparing a new prosthetic foot design using fiberglass composite material to traditional energy storage and return (ESR) designs using carbon fiber. “The findings of this study demonstrate that the new ESR foot comprised of a fiberglass material had better performance than traditional designs using a carbon fiber material,” he says. He also has completed a study comparing effects of MPK versus non-MPK knees for K2 amputees in 50 unilateral TFAs, assessed in “the free-living environment.” The subjects demonstrated improved outcomes when using an MPK, according to Kaufman. “Subjects reported a significant reduction

training them on “how to conduct research and provide clinical treatment that will be effective,” he says.

Defining New Pathways

In Kaufman’s work as a researcher and inventor, he sees several “pressing issues” to be explored via O&P research. “Caregivers, policy makers, and payors need outcomes-based data on which to base decisions,” he explains. “Objective evidence is currently limited. Clinicians lack definitive and reliable evidence to guide treatment plans for specific patients.” He believes there is variability within the rehabilitation community regarding which approaches should be taken. Currently, providers and payors must choose between providing advanced devices or less advanced technology, without predictive tools or definitive outcomes data to guide their decisions. “Studies have been performed [demonstrating] that advanced technology results in improved functional outcomes, but there is a lack of data to support specific treatment approaches,” he says. “If there were outcomes-based data available to guide and justify the selection of a given technology for a given patient population, then the clinician, insurer, and patient could be more confident that the most appropriate, beneficial, and cost-effective care was being provided.” The lack of patient outcomes data can impede clinicians’ abilities to make evidence-based decisions, according to Kaufman. “The need for improvement in the quality of care provided has been recognized nationally. It is time to collect outcomes data to guide patient care, compare patient-care approaches, quantify patient-centric outcomes, develop clinical practice guidelines, assess patient quality of life, and assess fitness for return to duty or work.”

Forging Partnerships, Calls to Action

Kaufman’s work at the Mayo Clinic has benefitted from several partnerships. His team has partnered locally with O&P providers and nationally with Hanger Clinic, as well as with U.S. Department of Defense (DOD) medical treatment facilities. O&P ALMANAC | JULY 2018

PRINCIPAL INVESTIGATOR

“All relationships are beneficial,” he says. “Our local providers provide excellent care and assist with new designs that are … not yet available commercially. Our national partners help greatly with subject recruitment to assure that we can perform larger size studies. Finally, our DOD partners provide the opportunity to extend our work to Wounded Warriors,” he says. Kaufman calls on O&P professionals to become O&P explorers themselves, by getting involved in research—at whatever level they feel comfortable. They can start by making

contact with current researchers. “When individuals who are interested in research attend regional and national meetings, they should make an attempt to introduce themselves to established research investigators,” he says. “Most, if not all, investigators welcome the opportunity to train the future generation of research investigators.” Newcomers to O&P research need look no further than the example set by Kaufman—by creating goals and exploring new territories, all can contribute to the growing O&P research well.

Notable Works and Accolades Kenton R. Kaufman, PhD, PE, has been an author on more than 250 peer-reviewed publications. Below is a sample of some of his most important publications: • Kaufman, K.R., Irby, S.E., Mathewson, J.W., Wirta, R.W., Sutherland, D.H. “Energy-Efficient Knee-Ankle-Foot Orthosis: A Case Study.” Journal of Prosthetic and Orthotics 1996. 8(3):79-85. • Irby, S.E., Bernhardt, K.A., Kaufman, K.R. “Gait of Stance-Control Orthosis Users: The Dynamic Knee Brace System.” Prosthetics and Orthotics International 2005. Dec;29(3):269-282. • Irby, S.E., Bernhardt, K.A., Kaufman, K.R. “Gait Changes Over Time in Stance-Control Orthosis Users.” Prosthetics and Orthotics International 2007. Dec;31(4):353-361. • Kaufman, K.R., Levine, J.A., Brey, R.H., Iverson, B.K., McCrady, S.K., Padgett, D.J., Joyner, M.J. “Gait and Balance of Transfemoral Amputees Using Passive Mechanical and Microprocessor-Controlled Prosthetic Knees.” Gait Posture 2007. Oct;26(4):489-493. • Kaufman, K.R., Levine, J.A., Brey, R.H., McCrady, S.K., Padgett, D.J., Joyner, M.J. “Energy Expenditure and Activity of Transfemoral Amputees Using Mechanical and Microprocessor-Controlled Prosthetic Knees.” Arch Phys Med Rehabil 2008. Jul;89(7):1380-1385. • Kaufman, K.R., Frittoli, S., Frigo, C.A. “Gait Asymmetry of Transfemoral Amputees Using Mechanical and Microprocessor-Controlled Prosthetic Knees.” Clin Biomech 2012. Jun;27(5):460-465. • Mundell, B.F., Maradit Kremers, H., Visscher, S., Hoppe, K.M., Kaufman, K.R. “Predictors of Receiving a Prosthesis for Adults With Above-Knee Amputations in a Well-Defined Population.” Physical Medicine and Rehabilitation 2016. 8:703-737. • Mundell, B.F., Maradit Kremers, H., Visscher, S., Hoppe, K., Kaufman, K.R. “Direct Medical Costs of Accidental Falls for Adults With Transfemoral Amputations.” Prosthetics and Orthotics International 2017. 41(6):564-570.

JULY 2018 | O&P ALMANAC

The results of Kaufman’s research have led to hundreds of articles for the general population, and he has appeared on nationally syndicated medical shows. In addition, he has received numerous awards and honors for his work, including the following: • Thranhardt Award, AOPA • Borelli Award for Outstanding Career Accomplishment, the American Society of Biomechanics (ASB) • Goel Award for Translational Biomechanics, ASB • Young Investigator Award, ASB • Excellence in Research Award, American Orthopedic Society for Sports Medicine (AOSSM) • O’Donoghue Sports Injury Research Award, AOSSM • Clinical Research Award, American Academy of Orthopedic Surgeons • Research Award, American Academy of Orthotists and Prosthetists • Best Scientific Paper Awards, Gait and Clinical Movement Analysis Society • Frank Stinchfield Award, The Hip Society • John Charnley Award, The Hip Society • John Insall Award, The Knee Society.

MEMBER SPOTLIGHT

NCOPI Goldsboro

By DEBORAH CONN

Serving His Country Facility owner draws from military experience to treat veterans—and other O&P patients

ILLIAM STAUFFER, CPO,

JULY 2018 | O&P ALMANAC

William Stauffer, CPO, with a patient who completed a 5-K run

FACILITY: North Carolina Orthotics & Prosthetics Inc., Goldsboro OWNER: William Stauffer, CPO LOCATION: Goldsboro, North Carolina HISTORY: 10 years

Stauffer with a patient who is a veteran of the Vietnam War

technology for patients requiring body jackets or scoliosis bracing, working with Boston Brace, which specializes in spinal orthoses. Because he is on his own, Stauffer uses an outside company to handle billing and reimbursement. He takes care of compliance issues himself. “I can always call AOPA or [the American Board for Certification in Orthotics, Prosthetics, and Pedorthics] if I have a problem,” he says. “If you follow their guidelines, there shouldn’t be an issue.” Most of Stauffer’s patients are older individuals with amputations caused by diabetes. He also works with active-duty military personnel from a nearby airbase and is working to strengthen his ties with the U.S. Department of Veterans Affairs (VA). “Because I’m a disabled veteran myself, I have connections to the military,” he explains. He works closely with the VA in Durham and in Fayetteville, serving prosthetic patients, as well as patients who need knee braces, shoe inserts, and other orthoses.

Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net.

PHOTOS: North Carolina Orthotics & Prosthetics Inc., Goldsboro

entered the O&P industry after an accident curtailed his military career as a tank gunner and commander. Unsure of what to do next, he and his wife, a physical therapist, researched career options pertaining to his interests, and he decided to pursue O&P. Stauffer graduated summa cum laude from the O&P program at California State University, a clear sign that he had chosen the right career path. Stauffer and his wife moved to the East Coast, where he completed a residency in Raleigh, North Carolina, and five years later launched a branch office of North Carolina Orthotics & Prosthetics Inc., or NCOPI, in Goldsboro. Eventually, Stauffer purchased the facility outright, although he continues to be part of the NCOPI network. Goldsboro was an ideal location to launch a new O&P office, Stauffer says, because it is roughly equidistant from three larger cities—the Raleigh-Durham area, Fayetteville, and Greenville— so he can serve patients who would otherwise have to drive 90 minutes or more for O&P care. The facility is conveniently located in a medical office park near Wayne Memorial Hospital and several skilled nursing facilities. The office utilizes digital technology and the latest white light scanners to capture 3-D models of patients. This information is sent to NCOPI’s fabrication facility in Wake Forest, North Carolina, for production of each custom device. Stauffer notes he uses the same digital

The orthotic-prosthetic ratio in his business is about 60-40. Stauffer fits a wide array of advanced devices, including microprocessor-controlled knees. “Patients need to feel like they are part of the process, and I am open when they say they saw something online. Patients are much more informed than they were 15 years ago, and that’s a good thing.” NCOPI Goldsboro markets via word of mouth, a facility website, and some local advertising. In addition, Stauffer is a member of the local chapter of Disabled Veterans of America, and he attends weekly breakfasts with fellow vets whenever he can. Stauffer says he can never get enough time to talk to fellow veterans. Stauffer attributes his success to his personal approach to patient care. “I make my own schedule and I decide how much time I need to spend with each patient,” he says. He enjoys seeing the results of meticulous care. “It’s rewarding designing an orthotic or prosthetic device and seeing it make a patient’s life better.” Looking ahead, Stauffer sees a bright future. “We are treating an increasing number of activeduty personnel and veterans. Our pediatric population also has been steadily increasing over the past few years,” he says. He plans to hire a bilingual front-office staffer, which he believes will be a great asset to the practice because of the growing Spanishspeaking population in the area. Stauffer is proud of his military service, and that he can continue to give back as a civilian. “Before I was injured, my job as a tank commander was to break things,” Stauffer says. “Now I’m in the business to fix things. It’s nice to be on the other end.”

O&P Care is Cost Effective

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Visit the MobilitySaves.org!

O&P CARE IS A SAVER, NOT AN EXPENSE TO INSURERS!

Reasons to visit MobilitySaves.org

Learn how access to Quality Care improves mobility.

Get Involved by sharing the Mobility Saves story on social media.

See Healthy Lives improved by access to O&P care.

Learn about The Data proving that access to O&P care saves lives.

Learn how orthotic and prosthetic care creates Cost Savings.

MEMBER SPOTLIGHT

Surestep

By DEBORAH CONN

Pediatric Problem Solvers

Indiana company offers custom orthotic solutions

JULY 2018 | O&P ALMANAC

A pediatric patient wears the Surestep SMO.

FACILITY: Surestep LOCATION: South Bend, Indiana OWNER: Employee owned HISTORY: 18 years

A Surestep technician works in the lab.

electronic gait analysis system that uses pressure mapping and video to measure many temporalspatial parameters of gait. This allows clinicians and the company’s research team to conduct case studies and document the long-term benefits of its devices. The Surestep SMO is primarily designed for children who pronate or who have low muscle tone, which can be caused by a variety of factors. What makes it different is its ability to stabilize in midline, while still allowing for the normal intrinsic movements of the foot. This facilitates a more natural development of the muscle strategies and movement patterns necessary for normal gait. “The foot needs to move a lot for children to develop balance reactions and learn how to stabilize themselves. Typical orthoses lock the foot in a static position, making it more and more dependent on the brace. We developed a thinner and lower profile that is more flexible,” says Veldman. In addition, modifications can be made to Surestep products, such as adding a posterior

Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net.

PHOTOS: Surestep

In the 1990s, Bernie Veldman, CO, worked with pediatric physical therapists at his brother-in-law’s O&P facility in Indiana. The clinical team was not satisfied with existing bracing options for children with hypotonia. Veldman knew the challenges first-hand. His son, Kevin, needed a device to stabilize his gait while allowing natural development. Veldman created a new type of supramalleolar orthosis (SMO) for his son that became the Surestep SMO. When it proved successful, he began offering this solution to patients. In 2000, Veldman and his wife, Pam, formed two companies in South Bend, Indiana. Surestep is the manufacturing arm, while Midwest Orthotic & Technology Center provides patient care. Both are now under the parent company Dienen. With 35 full-time O&P clinicians and a staff of more than 200, they provide services at 14 offices in six states. Dienen became a fully employee-owned company in January 2016. “Our employees are awesome people,” Veldman says. “We felt it was what we were called to.” The Surestep headquarters and production facility occupies roughly 30,000 square feet, with more than 100 technicians, clinicians, and customer service and support staff, and it features a fully equipped lab to handle the complete manufacturing process. Equipment includes two sevenaxis carvers, which help the company keep up with production demands. The company’s 40- by 70-foot gait lab includes an

extension to serve as a kinesthetic reminder for toe walkers to stay down. Aside from a few prefabricated components, Veldman adds, “Everything in a Surestep orthosis is custom made.” Another advantage of the device is that there’s no need for clinicians to provide cast molds. “They can simply email or fax measurements, and we can custom fabricate the SMO in two days,” says Suzi Klimek, executive marketing director. “If the authorization goes quickly, there’s no waiting for the device itself, allowing children to get their needs met much more quickly.” Surestep markets directly to orthotists, primarily through a large educational team that provides courses throughout the country and overseas. “We do about 80 to 100 in-services each year,” catering to physical therapists and local orthotists, says Veldman. The courses are approved for continuing education units. Surestep, which also manufactures devices for other companies, plans to expand its product line in the near future. After working with the University of Notre Dame for the past several years, Surestep launched an external ankle brace that can fit over shoes and cleats, allowing athletes to return to the game or injured workers to return to work much more quickly. “People with a sprained ankle can get back to work in days, not weeks,” says Veldman. Surestep provides manufacturing services, while a local company distributes and sells the device. Looking to the future, “We’re always looking for the next thing,” says Veldman, “to innovate again and make something that can change the lives of the children and adults we work with.”

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EARN CREDITS AT YOUR OWN PACE www.AOPAnetonline.org/aopaversity

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EARN SCIENTIFIC, BUSINESS, AND PEDORTHIC CE CREDITS BY STUDYING THE COURSE MATERIAL AND PASSING THE QUIZ.

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orthotic, prosthetic and pedorthic education and CE credits from the organization that knows O&P.

Itâ&#x20AC;&#x2122;s as easy as 1-2-3 1. Set up your free personal online account 2. Choose your education and study 3. Take the quiz and print your certificate Membership has its benefits:

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AOPA NEWS

AOPAversity Webinars AUGUST 8

SEPTEMBER 12

Outcomes & Patient Satisfaction Surveys

Medicare as Secondary Payor: Knowing the Rules

These days, data of all types is essential to running a successful and profitable O&P company. Learn more about designing and administering surveys at your facility so you can aggregate information to help you serve your patients better. Take part in the August 8 webinar, when AOPA experts will address these topics: • What is the importance of conducting patient satisfaction surveys? • How should the results of patient satisfaction surveys be analyzed? • Why is it important to track outcomes? • How can tracking outcomes help you provide better care to your patients?

Your source for advanced learning EARN CE CREDITS 56

JULY 2018 | O&P ALMANAC

There is a lot to know and understand when Medicare is a secondary payor. Take part in the September 12 webinar, and have all of your questions answered. • Find out which payors are primary to Medicare. • Learn to determine if Medicare is a secondary payor or a primary payor. • Find out how to calculate your payments from Medicare when it is a secondary payor. • Get educated about conditional payments. • Learn about set-aside arrangements.

AOPA members pay $99 (nonmembers pay $199), and any number of employees may participate on a given line. Attendees earn 1.5 continuing education credits by returning the provided quiz within 30 days and scoring at least 80 percent. Register at bit.ly/2018webinars. Contact Ryan Gleeson at rgleeson@AOPAnet.org or 571/431-0876 with questions. Sign up for the entire series and get two webinars free. All webinars that you missed will be sent as a recording. Register at bit.ly/2018webinars.

O&P PAC UPDATE

HE O&P PAC UPDATE provides infor-

mation on the activities of the O&P PAC, including the names of individuals who have made recent donations to the O&P PAC and the names of candidates the O&P PAC has recently supported. The O&P PAC would like to thank the following AOPA members for their recent contributions to the PAC:

W E CO RDIALLY INVITE Y O U TO ATTEND

• Curt Bertram, CPO, FAAOP • Jim Kingsley • Charles Kuffel, CPO, FAAOP • Theresa Kuffel, JD The purpose of the O&P PAC is to advocate for legislative or political interests at the federal level that have an impact on the orthotic and prosthetic community. The O&P PAC achieves this goal by working closely with members of the U.S. House of Representatives and Senate and other officials running for office to educate them about the issues, and help elect those individuals who support the orthotic and prosthetic community. To participate in, support, and receive additional information about the O&P PAC, federal law mandates that eligible individuals must first sign an authorization form, which may be completed online: bit.ly/pacauth.

Enjoy a night of ’70s soulful tunes, dinner, a silent auction, a disco dance off, and much more. Be there or be square. You are not required to wear your best ’70s threads, but we hope you will!

6:30-9:30 PM

September 27

2018

That Seventies Bar a.k.a. Convention Center Level 3-Summit

This is a special event and will require a separate registration fee. Certain rules and restrictions may apply. For additional information about Party With A Purpose or to register, visit AOPA Booth #302.

www.AOPAnet.org

NEW MEMBERS

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.

Limb Lab 400 S. Broadway, Ste. 106 Rochester, MN 55904 507/322-3457 Patient-Care Facility Marty Frana

Xi’an HSD Rehabilitation Appliance Co. Ltd. Northwest China Furniture Industrial Park Huaying Town, Lantian County, Xi’an Shaanxi Province (Xingang Ba Road) Xi’an, 710523 China +1 02532287579 International Member Qingcheng Tang

O&P ALMANAC | JULY 2018

AOPA NEWS

CAREERS

Opportunities for O&P Professionals

- Northeast

Pleasant Hill, Sacramento, and Oakland, California

- 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 landerson@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.

Color Ad Special 1/4 Page ad 1/2 Page ad

Member $482 $634

Listing Word Count 50 or less 51-75 76-120 121+

Member Nonmember $140 $280 $190 $380 $260 $520 $2.25 per word $5 per word

Nonmember $678 $830

ONLINE: O&P Job Board Rates Visit the only online job board in the industry at jobs.AOPAnet.org. Member Nonmember $85 $150

For more opportunities, visit: http://jobs.aopanet.org.

A large number of O&P Almanac readers view the digital issue— If you’re missing out, apply for an eSubscription by subscribing at bit.ly/AlmanacEsubscribe, or visit issuu.com/americanoandp to view your trusted source of everything O&P.

JULY 2018 | O&P ALMANAC

Collier O&P is a full-service orthotic and prosthetic patientcare facility with on-site fabrication. We are searching for a CO/CPO. The appropriate candidate will operate in a multioffice environment, so some travel is required. We offer a competitive salary/benefit structure commensurate with experience; it includes health, vacation, and continuing education.

Email your résumé to: Collier O&P Email: john@collieroandp.com Website: www.collieroandp.com

Mid-Atlantic

O&P Almanac Careers Rates

Certified Orthotist, Certified Prosthetist/Orthotist

Job location key:

Job Board

Pacific

Certified Orthotist

Fredericksburg, Virginia An orthotic and prosthetic company in Fredericksburg, Virginia, is seeking an ABC-certified orthotist. The ideal candidate needs to be motivated and dedicated to providing the best patient care possible. This person will be responsible for patient care, assessment/formulation of treatment plans, documentation, education, fabrication, and ordering proper components and supplies. We are a busy, growing prosthetic and orthotic company looking for the right person so that we may continue to expand our practice. This is a great opportunity for the right person to add to our orthotic department, which is very active with pediatrics to geriatrics. We offer a competitive benefits package and look forward to hearing from you. Interested candidates please email your résumé to Chris Taylor at chris@mobilitypo.com. Contact: Chris Taylor Email: chris@mobilitypo.com

CAREERS Inter-Mountain

Certified Prosthetic/Orthotic Clinicians

Albuquerque and Santa Fe, New Mexico Advanced Prosthetics and Orthotics is currently seeking skilled, dedicated, and hard-working ABC-certified prosthetic/orthotic clinicians for our Albuquerque and Santa Fe offices. CPOs and COs must possess a strong clinical background as well as provide quality and compassionate care. We offer competitive salary; medical, dental, vision, and retirement options are available.

DOWNLOAD the

“AOPA 365” App on your iPhone, Android or iPad Email: rocket4464@gmail.com

Download the

Mobile App!

Southeast

Certified Prosthetic/Orthotist

Tennessee Excellent Opportunity • Owner of a strong 20-year referral source getting ready to retire. • Looking for a resident just out of school or a CPO that wants to enjoy life in the East Tennessee mountains.

Download the app by either scanning the QR code or by searching the keyword AOPA365 in the Apple or Google stores.

This position has ownership possibilities. Contact: Tara Smallin Fax: 865/774-9959

Thank you to Our Supplier Plus Members

AOPA Supplier Plus Partners

Thank You to Our AOPA Supplier Plus Partners

O&P ALMANAC | JULY 2018

MARKETPLACE

Feature your product or service in Marketplace. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net. Visit bit.ly/almanac18 for advertising options.

ALPS Anterior Posterior Tapered Liner ALPS AP Tapered Liner is gradually tapered from the anterior to the posterior to provide superior comfort. This liner is available in a pin-and-lock system or suction suspension. The AP Tapered Liner features our black high-performance fabric with gel to assist in reducing bunching in the popliteal region. Call us or visit www.easyliner.com for more details.

Huge Price Reduction on Coyote Composite

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.

Pro-Flex®—Less load, more dynamics™ HUGE Price Reduction on Coyote Composite

“ITCHING” for a new material? • Nontoxic, noncarcinogenic, and inert alternative to carbon fiber. • Has little to no itch. • Made from basalt (lava rock), a 100 percent natural fiber. We found you can save at least 31 percent by using Coyote Composite compared to carbon fiber. For a list price and a more comprehensive list of reasons why you should switch to Coyote Composite, go to www.coyotedesign.com. For more information, contact Coyote Design at 208/429-0026.

Fabtech Systems 3-D-Printing Capabilities Fabtech Systems and Extremiti-3D provide the highest quality 3-D-printed prosthetic devices to the O&P industry. Products provided: Protective covers, above-knee and below-knee sockets. Features: • Precise form, fit, and functionality your patients deserve • Twenty industry standard skin tones and 16 custom protective cover designs • Reformable definitive for individual customization • Carbon additives provide long lasting durability • Eliminates pulling deformities encountered with manual fabrication • 3-D printed to your exact measurements. For more information, call 800/322-8324 or visit www.fabtechsystems.com. 60

JULY 2018 | O&P ALMANAC

Introducing Pro-Flex LP Align, which couples up to 2 3/4 inches of heel height adjustability with the mechanical power of the three-blade Pro-Flex design. So users can maintain proper alignment across a variety of everyday footwear, from sandals to sneakers to dress shoes. Visit ossur.com/pro-flex-family or ask your Össur representative about a Pro-Flex demo today.

Keeping Up With Kids Ottobock’s 3R67™ children’s knee joint is a prosthesis with hydraulic stance and swing phase control specifically adapted for young users. The knee meets the everyday demands of children during a myriad of activities, including different walking and running speeds and a flexion angle of up to 150 degrees for maximum freedom of movement. For everyday use, it can be worn with the robust 1K10 foot. For more information visit: professionals.ottobockus.com.

MARKETPLACE 2018 AOPA Coding Products

Ottobock Omo Neurexaplus Shoulder Orthosis Redefine recovery with Ottobock’s Omo Neurexaplus. The shoulder orthosis facilitates active rehabilitation by correctly positioning the arm and promoting movement for patients with shoulder subluxation. The Omo Neurexaplus 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.

TRS “KIDDO” Criterium Pivot Available NOW! Introducing the “KIDDO” for children tricycling and bicycling. The WEDGE design with integral radial, ulnar pivoting action, provides greater versatility, control, and safety for the rider. The two models (soft and firm) have different flexibilities and a “clasping action” on the handlebars. The KIDDO is less than three inches long, lightweight (6 oz.), and fits both left and right prostheses. Priced inexpensively, the KIDDO is available for kids three years old and up. For more information, contact TRS Inc. at 800/279-1865 or visit trsprosthetics.com.

Get your facility up to speed, fast, on all of the O&P Health-Care Common Procedure Coding System (HCPCS) code changes with an array of 2018 AOPA coding products. Ensure each member of your staff has a 2018 Quick Coder, a durable, easy-to-store desk reference of all of the O&P HCPCS codes and descriptors. • 2018 Coding Suite (includes CodingPro single user, Illustrated Guide, and Quick Coder): $350 AOPA members, $895 nonmembers • 2018 CodingPro CD-ROM (single-user version): $185 AOPA members, $425 nonmembers • 2018 CodingPro CD-ROM (network version): $435 AOPA members, $695 nonmembers • 2018 Illustrated Guide: $185 AOPA members, $425 nonmembers • 2018 Quick Coder: $30 AOPA members, $80 nonmembers. Order at www.AOPAnet.org or call AOPA at 571/431-0876.

AD INDEX

Advertisers Index Company Allard ALPS Amfit Cailor Fleming Insurance Coyote Design Custom Composite Fabtech Systems LLC Flo-Tech O&P Systems Inc. Hersco Naked Prosthetics Orthomerica Össur Ottobock

Page

Phone

27 866/678-6548 7 800/574-5426 47 800/356-3668 35 800/796-8495 17 800/819-5980 51 866/273-2230 15 1-800-FABTECH 37 800/356-8324 1 800/301-8275 21 888/977-6693 9 800/446-6770 3 800/233-6263 C4 800/328-4058

Website www.allardusa.com www.easyliner.com www.amfit.com www.cailorfleming.com www.coyotedesign.com www.cc-mfg.com www.fabtechsystems.com www.1800flo-tech.com www.hersco.com www.npdevices.copm www.orthomerica.com www.ossur.com www.professionals.ottobockus.com

O&P ALMANAC | JULY 2018

CALENDAR

2018

July 13–14

July 9–14

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.

July 11

Administrative Documentation: WEBINAR What Is Always Needed and What Is Sometimes Needed? Register online at bit.ly/2018webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

July 13

PrimeFair East—The Providence Nocturnal Scoliosis System. Downtown Hilton, Nashville, TN. 8:00 a.m.- 12:15 p.m. This course instructs orthotists on the use of a nocturnal orthotic system for the nonsurgical treatment of adolescent idiopathic, juvenile, and neuromuscular scoliosis. The program will educate on how to satisfactorily address the needs of patients via thorough review of scoliosis principles and the use of innovative technology to optimize fit, comfort, and compliance while stopping curve progression in a nocturnal-only setting. Presented by Barry McCoy, CPO, Spinal Technology Inc.

PrimeFare East Regional Scientific Symposium. Hilton Downtown Nashville. Contact 888/388-5243, email primecarepruitt@gmail.com, or visit www.primecareop.com. 20th Anniversary of PrimeFare East!

July 23–24

2018 Mastering Medicare: Essential Coding & Billing Techniques Seminars. St. Louis. Register online at bit.ly/2018billing. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. Coding & Billing Seminar

August 1

ABC: Practitioner Residency Completion Deadline for September Certification Exams. All practitioner candidates have an additional 30 days after the application deadline to complete their residency. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.

August 1

ABC: Application Deadline for ABC/OPERF Resident Travel Award. Four residents will be selected to present their Directed Study Research project at the 2018 Academy Annual Meeting and receive $2,500 plus complimentary meeting registration. For more info or to apply, go to operf.org.

August 8

Outcomes & Patient Satisfaction Surveys. Register online at bit.ly/2018webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR

Apply Anytime!

Apply anytime for COF, CMF, CDME; test when www.bocusa.org ready; receive results instantly. Current BOCO, BOCP, and BOCPD candidates have three years from application date to pass their exam(s). To learn more about our nationally recognized, in-demand credentials, or to apply now, visit www.bocusa.org.

Calendar Rates Let us

your next event!

JULY 2018 | O&P ALMANAC

Free Online Training

Cascade Dafo Institute. Cascade Dafo Institute offers eight free ABC-approved online continuing education courses for pediatric practitioners. Earn up to 12.25 CE credits. Visit cascadedafo.com or call 800/848-7332.

CE For information on continuing education credits, contact the sponsor. Questions? Email landerson@AOPAnet.org.

CREDITS

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 landerson@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

CALENDAR

August 10–11

The Texas Chapter of the American Academy of Orthotists and Prosthetists 2018 Annual Meeting. Westin Galleria, Dallas. For information and registration, visit www.txaaop.org

September 1

ABC: Application Deadline for Certification Exams. Applications must be received by September 1 for individuals seeking to take the November Written and Written Simulation certification exams. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.

September 7–8

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.

October 20

Advancements in Conservative Treatments of Scoliosis. San Mateo, CA. Schroth instructors, orthotists, and MDs from around the country will be joining us to discuss topics relating to conservative and surgical scoliosis treatment. Grant Wood, Align Clinic, & Beth Janssen, Scoliosis Rehab. For more information, visit www.align-clinic.com or email evaldez@align-clinic.com.

November 4–10

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.

November 7–9

NJAAOP. Harrah’s, Atlantic City, NJ. For more information, visit www.njaaop.com. Contact Brooke Artesi, CPO, LPO, with questions at Brooke@sunshinepando.com.

September 12

Medicare As a Secondary Payor: Knowing the Rules. Register online at bit.ly/2018webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR

November 12–13

2018 Mastering Medicare: Essential Coding & Billing Techniques Seminars. Las Vegas. Register online at bit.ly/2018billing. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. Coding & Billing Seminar

September 17–22

September 26–29

AOPA National Assembly. Vancouver Convention Center. For general inquiries, contact Ryan Gleeson at 571/431-0876 or rgleeson@AOPAnet.org, or visit www.AOPAnet.org.

October 10

Year-End Review: What Should You Do To Wrap Up the Year & Get Ready for the New Year? Register online at bit.ly/2018webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR

October 18–20

International African-American Prosthetic Orthotic Coalition Annual Meeting. Embassy Suites Downtown Medical Center, Oklahoma City. For more information, contact Tony Thaxton Jr. at 404/875-0066, email thaxton.jr@comcast.net, or visit www.iaapoc.org.

November 14

Evaluating Your Compliance Plan & Procedures: How To Audit Your Practice. Register online at bit.ly/2018webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR

November 28–30

New England Chapter AAOP. Please join us at Mohegan Sun in Connecticut for an outstanding ABC/BOC continuing education program. Registration and more information at www.neaaop.org

December 12

New Codes, Medicare Changes, & Updates. Register online at bit.ly/2018webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR

2019 September 25–28

AOPA National Assembly. San Diego Convention Center. For general inquiries, contact Ryan Gleeson at 571/431-0876 or rgleeson@AOPAnet.org, or visit www.AOPAnet.org.

O&P ALMANAC | JULY 2018

ASK AOPA CALENDAR

Partnering With Physicians Reviewing the rules on shared spaces

AOPA receives hundreds of queries from readers 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.

May we share space with a physician’s office?

The Medicare Supplier Standards state that two suppliers may not share the same physical address. So, if the physician already has a supplier number—meaning the physician is billing Medicare for items in the durable medical equipment, prosthetics, orthotics, and supplies category—then you may not share space. There is an exception to this rule if you are in a separate suite and the suite is recognized by the U.S. Postal Service, and it meets all of the other Supplier Standard requirements.

Can we rent space in a physician’s office?

This ties in with the previous question. Yes, you are able to rent space from a physician, but you must keep two important considerations in mind. First, the rent you are paying for the space must be a fair and marketable rate, meaning it should be comparable to other rents in the area. Second, the rent and the value of the rent must not, in any way, be tied to the amount of referrals received.

JULY 2018 | O&P ALMANAC

Are we allowed to see patients in a physician’s office, and if so, are we required to have a National Provider Identifier (NPI) number and Provider Transaction Access Number (PTAN) for that location?

You are required to have an NPI number for any location where you see and treat patients. However, if you are seeing a patient at his or her physician’s office out of a courtesy or convenience to the patient, then you would not need a PTAN. If you are routinely setting up shop in a physician’s office with routine hours, then you should evaluate the situation. Remember that if you deliver an item in the physician’s office, you must use the physician’s office as the delivery address on the proof of delivery.

Can a physician operate or have an orthotic and prosthetic component to his or her organization, or does this violate the Stark laws?

It is possible for a physician to have an orthotic and prosthetic component to his or her business and not violate the self-referral, or Stark, laws, as there are safe harbors. In a nutshell, if the orthotic and prosthetic component is a separate company and the physician has a stake in the company, then there could be violations. However, if the orthotic and prosthetic company is part of the overall services provided by the physician and his or her group, then it would not be considered a self-referral violation.

AOPA Coding Experts Are Coming to

Las Vegas

November 12-13

ATLANTA

FEB. 26-27 | 2018

AOPA MASTERING MEDICARE:

ESSENTIAL CODING & BILLING TECHNIQUES SEMINAR Join AOPA July 23-24 in St. Louis to advance your 14 CEs O&P practitioners’ and billing staff ’s coding knowledge. Join AOPA for this two-day event, where you will earn 14 CEs and get up-to-date on all the hot topics.

EARN

AOPA experts provide the most up-todate information to help O&P practitioners and office billing staff learn how to code complex devices, including repairs and adjustments, through interactive discussions with AOPA experts, your colleagues, and much more. Meant for both practitioners and office staff, this advanced two-day event will feature breakout sessions for these two groups, to ensure concentration on material appropriate to each group.

Don’t miss the opportunity to experience two jam-packed days of valuable O&P coding and billing information. Learn more and see the rest of the year’s schedule at bit.ly/2018billing.

The Tropicana Las Vegas 3801 S Las Vegas Blvd Las Vegas, NV 89109 Book your hotel by October 24 for the $95/night rate by calling 800/648-4462.

Top 10 reasons to attend: 1.

Get your claims paid.

Increase your company’s bottom line.

Stay up-to-date on billing Medicare.

Code complex devices

Earn 14 CE credits.

Learn about audit updates.

Overturn denials.

Submit your specific questions ahead of time.

Advance your career.

10. AOPA coding and billing experts have more than 70 years of combined experience. Find the best practices to help you manage your business.

Participate in the 2018 Coding & Billing Seminar!

For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. .

www.AOPAnet.org

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