May 2015 O&P Almanac by AOPA

The Magazine for the Orthotics & Prosthetics Profession

MAY 2015

E! QU IZ M EARN

Tips for Billing Returned and Refused Items

BUSINESS CE

CREDITS P.16

P.14

O&P Brings Hard Data and a Fresh Perspective to Capitol Hill P.30

How To Handle ‘Noncovered’ Items P.56

Children and Obesity WWW.AOPANET.ORG

How orthotists adjust treatments to ensure optimal outcomes for a number of pathologies P.22

Exclusive: What ‘Doc Fix’ Means for O&P P.18

YOUR CONNECTION TO

EVERYTHING O&P

American Orthotic & Prosthetic Association The premier meeting for orthotic, prosthetic, and pedorthic professionals

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Experience an ideal combination of top-notch education, exhibits, and entertainment at the 98th AOPA National Assembly in San Antonio, Texas. We look forward to seeing you!

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The 98th Annual AOPA National Assembly and combined Texas Academy Chapter Meeting October 7-10, 2015 The Henry B. Gonzalez Convention Center On the Riverwalk in San Antonio, TX

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MAY 2015 | VOL. 64, NO. 5

FEATURES COVER STORY

DEPARTMENTS | COLUMNS President’s View....................................... 4

Insights from AOPA President Charles Dankmeyer, Jr., CPO

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

Numbers........................................................ 8

At-a-glance statistics and data

Happenings............................................... 10

Research, updates, and industry news

People & Places........................................ 13

22 | Weighty Issues

Transitions in the profession

As childhood obesity reaches epidemic proportions in the United States, orthotists are challenged to meet the needs of heavier pediatric patients. With excess weight comes a greater risk for bone and joint problems, as well as an increased risk for several musculoskeletal conditions. Treating overweight patients to ensure optimal function and durability of orthoses—and best patient outcomes—requires both expertise and sensitivity. By Christine Umbrell

18 | This Just In

The Point of No Return? Understand the billing guidelines for refused and returned O&P devices

CE Opportunity to earn up to 2 CE credits by taking the online quiz.

CREDITS

Member Spotlights............................... 38 n

P. 18

What ‘Doc Fix’ Means for O&P The repeal of the sustainable growth-rate method as a means of determining Medicare physician pay marked the first major legislative accomplishment of the 20152016 Congress. The law sets the stage for a transition to value-based physician reimbursement and alternative payment methods, which O&P practitioners must keep in mind as they consider partnership opportunities in the years ahead.

Reimbursement Page.......................... 14

DOC FIX

Grace Prosthetic Fabrication Inc. Presque Isle Medical Technologies

P. 40

P. 30 AOPA News................................................42

30 | A Policy Forum for All Ages

AOPA meetings, announcements, member benefits, and more

Practitioners, advocates of the profession, and O&P students descended upon Capitol Hill in March to take part in AOPA’s 2015 Policy Forum. This year, participants were armed with hard data on the value O&P brings to the patient rehabilitation process, and shared that message with hundreds of lawmakers.

Welcome New Members .................. 47

By Adam Stone

Upcoming meetings and events

Marketplace............................................. 48

Careers......................................................... 52

Professional opportunities

Calendar...................................................... 54

Ad Index....................................................... 55

Advertise with Us! For advertising information, contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net.

Ask AOPA................................................... 56 Expert answers to your questions about “noncovered” items

O&P ALMANAC | MAY 2015

PRESIDENT’S VIEW

Working Toward a Common Goal

Specialists in delivering superior treatments and outcomes to patients with limb loss and limb impairment.

NE OF THE MESSAGES I sent when I came into this office was that the O&P organizations—all of them—should be ashamed for their lack of coordination and focus. Every facility and practitioner spends a significant amount of money supporting the organizations, only to watch too much of it frittered away in petty squabbles between the organizations. You know what I mean. There is a lack of information sharing between the organizations. Whose credential is the most valid? Is that a business program, or is it clinical content? Should AOPA be researching that topic, or does it belong in the purview of the Academy? Whose constituents are most affected by regulations that identify qualified providers and qualified suppliers? Who is responsible to represent the credentialed professional and accredited facility to thirdparty payors? What legislation or regulation should be supported or opposed? Are we sending mixed messages to regulators? When is the O&P Alliance most useful? Answering these questions can be a virtually endless and wasteful task. Wasteful of your dues and fees, and wasteful of the talent that has been installed on each board. AOPA and the American Academy of Orthotists and Prosthetists (AAOP) both provide valuable support to the profession and their constituents. These two organizations have recognized the need to use their talent and resources most effectively. I am pleased to report that AAOP and AOPA have made a significant step to coordinate the research activities of both organizations and to cooperate in defining those areas where research is most needed. This may seem like a small thing to you, but consider the importance of having studies that prove the effectiveness of O&P treatments—whether it is scoliosis management, post stroke, K2 versus K3 patients with microprocessor knees and ankles, stance control orthoses, or any of a number of other topics. The cost to do research to prove that treatment is effective is enormous. We work to draw in funds from a variety of sources, but ultimately both AOPA and AAOP shoulder a large amount of the expense. To better serve the profession, the two organizations have developed a cross pollination of tasks. No longer will it be possible to have parallel studies on similar topics. AOPA and AAOP will work together developing research initiatives. The progress of studies will be reported to both organizations. The results of these studies will provide proof that the care provided by each professional and each member practice facility improves the quality of life and is cost effective. Both organizations share the same committee to select research topics and rank them in order of importance. Small step, you say? Maybe, but it is a first one, and we think it is already bearing fruit. Yet, when I attend national meetings, I still hear people expressing loyalty to one organization and disparaging the other. I have to ask those people, where is your loyalty to the profession? I am glad that AOPA and AAOP are working their way out of gridlock. I think it is a good thing—what do you think? Email info@AOPAnet.org.

Board of Directors OFFICERS

President Charles H. Dankmeyer Jr., CPO Dankmeyer Inc., Linthicum Heights, MD President-Elect James Campbell, PhD, CO, FAAOP Becker Orthopedic Appliance Co., Troy, MI Vice President Michael Oros, CPO, FAAOP Scheck and Siress O&P Inc., Oakbrook Terrace, IL Immediate Past President Anita Liberman-Lampear, MA University of Michigan Orthotics and Prosthetics Center, Ann Arbor, MI Treasurer Jeff Collins, CPA Cascade Orthopedic Supply Inc., Chico, CA Executive Director/Secretary Thomas F. Fise, JD AOPA, Alexandria, VA DIRECTORS Maynard Carkhuff Freedom Innovations, LLC, Irvine, CA Eileen Levis Orthologix LLC, Trevose, PA Pam Lupo, CO Wright & Filippis Inc., Rochester Hills, MI Jeffrey Lutz, CPO Hanger Clinic, Lafayette, LA Dave McGill Össur Americas, Foothill Ranch, CA Chris Nolan Endolite, Miamisburg, OH Scott Schneider Ottobock, Austin, TX

Charles H. Dankmeyer Jr., CPO AOPA President

MAY 2015 | O&P ALMANAC

Don Shurr, CPO, PT American Prosthetics & Orthotics Inc., Iowa City, IA

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AOPA CONTACTS

American Orthotic & Prosthetic Association (AOPA) 330 John Carlyle St., Ste. 200, Alexandria, VA 22314 AOPA Main Number: 571/431-0876 AOPA Fax: 571/431-0899 www.AOPAnet.org

Publisher Thomas F. Fise, JD Editorial Management Content Communicators LLC

Our Mission Statement The mission of the American Orthotic & Prosthetic Association is to work for favorable treatment of the O&P business in laws, regulation and services; to help members improve their management and marketing skills; and to raise awareness and understanding of the industry and the association.

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

EXECUTIVE OFFICES

REIMBURSEMENT SERVICES

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

Joe McTernan, director of coding and reimbursement services, education and programming, 571/431-0811, jmcternan@ AOPAnet.org

Don DeBolt, chief operating officer, 571/431-0814, ddebolt@AOPAnet.org

MEMBERSHIP & MEETINGS Tina Moran, CMP, senior director of membership operations and meetings, 571/431-0808, tmoran@AOPAnet.org Kelly O’Neill, CEM, manager of membership and meetings, 571/431-0852, koneill@AOPAnet.org Lauren Anderson, manager of communications, policy, and strategic initiatives, 571/431-0843, landerson@AOPAnet.org Betty Leppin, manager of member services and operations, 571/431-0810, bleppin@AOPAnet.org Yelena Mazur, membership and meetings coordinator, 571/431-0876, ymazur@AOPAnet.org Ryan Gleeson, meetings coordinator, 571/431-0876, rgleeson@AOPAnet.org AOPA Bookstore: 571/431-0865

MAY 2015 | O&P ALMANAC

Devon Bernard, assistant director of coding and reimbursement services, education, and programming, 571/431-0854, dbernard@ AOPAnet.org Reimbursement/Coding: 571/431-0833, www.LCodeSearch.com

O&P ALMANAC Thomas F. Fise, JD, publisher, 571/431-0802, tfise@AOPAnet.org Josephine Rossi, editor, 703/662-5828, jrossi@contentcommunicators.com Catherine Marinoff, art director, 786/293-1577, catherine@marinoffdesign.com Bob Heiman, director of sales, 856/673-4000, bob.rhmedia@comcast.net Christine Umbrell, editorial/production associate and contributing writer, 703/662-5828, cumbrell@contentcommunicators.com

Advertising Sales RH Media LLC Design & Production Marinoff Design LLC Printing Dartmouth Printing Company 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 almanac@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 © 2015 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.

Advertise with Us! Reach out to AOPA’s membership and 15,000 subscribers. Engage the profession today. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net. Visit bit.ly/aopamedia for advertising options!

NUMBERS

As the Affordable Care Act (ACA) takes effect, there are fewer uninsured Americans, but most “covered” individuals still pay a wide array of health expenses due to co-pays, deductibles, and other out-of-pocket medical expenses.

COSTS OF EMPLOYER-SPONSORED HEALTH PLANS

$16,384

$4,823

Average amount employees expected to pay toward employersponsored health plans in 2014.

Average cost of an employersponsored health plan in 2014, up 3 percent from 2013.

WORKERS PAY ONE QUARTER OF EMPLOYEE-SPONSORED INSURANCE PREMIUMS

ACA DEFINES OUT-OFPOCKET MAXIMUMS

Percentage of insurance premiums for single coverage paid by employees in 2014.

Maximum out-of-pocket cost for self-coverage for ACA marketplace plans in 2014 (rising to $6,600 in 2015).

29 percent

$12,700

Percentage of insurance premiums for family coverage paid by employees in 2014.

Maximum out-of-pocket cost for family coverage for ACA marketplace plans in 2014 (rising to $13,200 in 2015).

MORE AMERICANS SEEK NEEDED HEALTH CARE

Number of Adults, Ages 19-64, Who Reported Not Getting Needed Medical Care Because of Cost

Had a medical problem, did not visit doctor or clinic Did not fill a prescription Skipped a recommended test, treatment, or follow up Did not get needed specialist care

2010 2012 2014 26% 26%

29% 27%

23% 19%

25% 18%

27% 20%

19% 13%

Source: “The Rise in Health-Care Coverage and Affordability Since Health Reform Took Effect,” January 2015, The Commonwealth Fund.

MAY 2015 | O&P ALMANAC

2 in 5 Fraction of privately insured U.S. households that don’t have enough liquid financial assets to cover a midrange health deductible.

52 percent

Percentage of debt collections arising from medical debt on consumer credit reports.

$6,350

18 percent

In the past 12 months:

MANY STILL STRUGGLE TO PAY MEDICAL BILLS

“The relatively slow growth in premiums [in 2014] is good news for employers and workers, though many workers now pay more when they get sick as deductibles continue to rise and skin-in-the-game insurance gradually becomes the norm.” —Kaiser Family Foundation President and CEO Drew Altman, PhD

Sources: “The Rise in Health-Care Coverage and Affordability Since Health Reform Took Effect,” January 2015, The Commonwealth Fund; The Kaiser Family Foundation; Consumer Financial Protection Bureau; healthcare.gov.

Out-of-Pocket Medical Costs

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Happenings RESEARCH ROUNDUP

Researchers Develop Brain-Machine Interface for Prosthetic Grasping University of Houston (UH) researchers have created an algorithm designed to harness an amputee’s thoughts to allow that individual to grasp objects with a prosthetic hand. The study, funded by the National Science Foundation, demonstrates for the first time an electroencephalogram (EEG)-based brain-machine control of a multifingered prosthesis for grasping. The UH researchers used a noninvasive brain-monitoring technique to capture brain activity and establish which parts of the brain are involved in grasping for a 56-year-old hand amputee. Using that information, as well as brain activity data garnered

from nonamputee study participants, the research team designed a brainmachine interface that captured the subject’s intentions, enabling him to successfully grasp objects such as a water bottle and credit card using a prosthetic hand. During clinical trials, the subject grasped the selected

objects 80 percent of the time. The new method avoids the risks of surgically implanting electrodes by measuring brain activity via scalp EEG, says Jose Luis Contreras-Vidal, a neuroscientist and engineer at the University of Houston. UH researchers say the study offers a new understanding of the neuroscience of grasping and will be applicable to rehabilitation for other types of injuries, including stroke and spinal cord injury. Details of the study, which researchers say may lead to the development of better prostheses, are published in the March 30 edition of Frontiers in Neuroscience.

Clinical Trial Targets Chronic Amputee Pain Northwestern Medicine researchers have begun a four-year multicenter clinical trial to evaluate targeted muscle reinnervation (TMR) as a solution to treat veteran and civilian amputees for chronic pain that results from limb amputation. The study, funded by the Department of Defense’s Office of Congressionally Directed Medical Research, will study phantom limb syndrome, which prevents some patients from using prostheses. Northwestern Memorial Hospital is the lead site for the study; other participating sites include Walter Reed National Military Medical Center, The University of Washington Medical Center and Harborview Medical Center, and San Antonio 10

MAY 2015 | O&P ALMANAC

Military Medical Center. The goal of the TMR therapy adapted for this study is to transfer a nerve that has been cut off from the muscles it previously controlled and plug it into a functioning muscle. During this procedure, a surgeon removes the neuroma from the damaged nerve and then joins it with a healthy nerve that controls the existing target muscle. Joining these nerves enabled them to reinnervate the target muscle and prevent the neuroma from reforming. “TMR is a completely new approach to treating neuroma-induced pain for amputees,” says co-investigator Todd Kuiken, MD, PhD, a Northwestern Medicine physiatrist who is director of the Center for Bionic Medicine

at the Rehabilitation Institute of Chicago and professor of surgery at the Northwestern University Feinberg School of Medicine. “Instead of trying to treat a painful neuroma by burying it, this procedure provides damaged nerves with a new purpose. After TMR, patients can use these previously unable nerves to contract their target muscle and their repurposed signals can even be detected and used to control prostheses.” Participants in the clinical trial will complete an online pain questionnaire and undergo magnetic resonance imaging of the nerves treated before and after surgery to compare the outcomes of TMR and the current standard surgical treatment for painful neuromas.

HAPPENINGS

CODING CORNER

Jurisdiction D Publishes Results of Prepayment Audits for L5980 Noridian Healthcare Solutions LLC, which serves as the Jurisdiction D durable medical equipment Medicare administrative contractor (DME MAC), has released the results of prepayment audits for prosthetic feet described by L5980. From November 2014 until February 2015, Noridian reviewed 56 claims, of which 42 were denied. Based on dollars, this represents a claim denial rate of 67 percent. While this is certainly not encouraging news, it does continue a downward trend in the overall denial rate. Noridian began auditing claims for L5980 in January 2013 and has had consistent denial rates in the mid 80 percent range since. The significant drop in denial rate during the first quarter of 2015 is somewhat encouraging as it indicates that providers are finally able

Number of L5980 codes recently denied in Jurisdiction D:

42 out of 56 to obtain some of the specific documentation that the DME MACs are looking for. In order for Medicare to deem prosthetic feet described by L5980 as medically necessary, there must be documentation in both the prescribing physician’s record and the provider’s records that support a K3 functional level assessment for the patient.

Jurisdiction C Reports Audit Results for OTS Diabetic Shoes CGS, the contractor that serves as the Jurisdiction C DME MAC, has reported the results of its ongoing prepayment review of claims for off-the-shelf (OTS) diabetic shoes described by code A5500. For the fourth quarter of 2014, the claim denial rate was 75 percent. While the latest report continues to show a steady reduction in claim denials, from a high of 87 percent in the fourth quarter of 2013, a 75 percent denial rate remains too high for CGS to consider discontinuing its prepayment review. It is important for AOPA members to thoroughly review the local coverage determination and policy article that together govern Medicare coverage of diabetic shoes. The only way to stop these prepayment reviews is to

Jurisdiction C Denial Rate for Code A5500 Q4 2013:

87%

Q4 2014:

75%

DIABETES DOWNLOAD

Researcher Identifies Gender Differences in Diabetic Foot Amputations Studies of avoidable hospitalizations for diabetes-related lower-extremity amputation have shown consistent patterns of differences between the sexes, says Monica Peek, MD, MPH, an assistant professor in the division of general internal medicine at the University of Chicago. She spoke on this topic during a research symposium on musculoskeletal health-care disparities sponsored by the American Academy of Orthopaedic Surgeons. Peek studied data from a 2006 study based on data from the Agency for Healthcare Research and Quality’s Medical Expenditure Panel Survey as well as its Healthcare Cost and Utilization Project. She found a rate of 55 lower-extremity amputations in male diabetes patients per 100,000 population compared to 28 lowerextremity amputations in women. Differences in men and women also persist across racial and ethnic groups, according to the research. Peek also found that male patients are younger than female patients at the time of amputation.

Diabetes Amputation Rates MEN:

WOMEN:

PER 100,000

lower the claim denial rate to a level that is acceptable to the DME MAC. A detailed report of the main reasons for A5500 claim denials may be found at www.cgsmedicare.com/jc/ pubs/news/2015/0215/cope28328.html. O&P ALMANAC | MAY 2015

HAPPENINGS

COMPETITIVE BIDDING

#ICYMI

Legislation Seeks Relief From O&P Challenges OTS Orthoses Will Not Be Included in Next Round

The product categories and metropolitan statistical areas that will be included in the next round of competitive bidding for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) were revealed on April 21. Off-the-shelf (OTS) orthoses were not among the eight product categories identified for inclusion in the Round 1, 2017, competitive bidding program. Prior to the announcement, it appeared that OTS orthoses were being considered for inclusion in DMEPOS competitive bidding. The fact that these items are not on the list for the next round “does not mean that OTS orthoses will not be included in competitive bidding at some point,” said Joe McTernan, AOPA’s director of reimbursement services. “The descriptor changes that were implemented in 2014 to clearly distinguish OTS orthoses from custom-fitted orthoses certainly indicate the intent of CMS to eventually include OTS orthoses in competitive bidding at some point in the future.” AOPA leaders plan to continue their ongoing discussion with CMS regarding their concern about the continued expansion of those items considered “OTS orthoses.” Details on the categories that will be included for Round 1, 2017, can be found on the CMS website at www.cms.gov.

MAY 2015 | O&P ALMANAC

Seldom does a single piece of legislation do so much for a vital segment of patients and health-care providers as does the new version of the Medicare O&P Improvement Act of 2015. This legislation was introduced by Sens. Chuck Grassley (R-Iowa) and Mark Warner (D-Virginia) in the Senate (S. 829) and by Reps. Glenn Thompson (R-Pennsylvania) and Mike Thompson (D-California) in the House (H.R. 1530). Three of the four sponsors have previously sponsored versions of the bill; adding Senator Warner to the Senate version continues the bipartisan support this legislation has always generated. Introduction of the bills on March 23, 2015, on the opening day of AOPA’s Policy Forum, paved the way for O&P’s relief from the following patient-care and business disruptions experienced over the past five years by: • Curbing overzealous audits • Denying payments to unlicensed/ unqualified providers • Recognizing orthotists’ and prosthetists’ notes by stating that they “shall be considered part of the medical record” • Separating orthotics and prosthetics from durable medical equipment (DME) • Resolving the illegal delays for appealing denied claims to the administrative law judge, by adjustments to the recoupment policy • Offering a voluntary negotiation process to provide a prompt equitable settlement, similar to the process available to hospitals • Requiring CMS to separate appeals process data so O&P claim

outcomes are tracked and reported separately from other DME claims • Mandating CMS to adhere to the statutory definition of off-the-shelf orthotics eligible for competitive bidding as only being those needing “minimal self adjustment” by the patient, and no other person. Visit bit.ly/policyforum to view the bills. In addition, Rep. Mark Meadows (R-North Carolina) recently introduced H.R. 1526. This bill accomplishes improvements to the existing chaotic Recovery Audit Contractor (RAC) audit situation through provisions that recognize that the orthotists’ and prosthetists’ notes “shall be considered as part of the medical record of the individual.” The bill also requires CMS to separately report determinations made on O&P claim denials/appeals as well as the Health-Care Common Procedure Coding System codes accounting for the greatest number of determinations and the total dollars involved. Under the bill, no more than “half of the amount of any payments made” to a qualified supplier may be recouped before that appeals process for such a claim is treated as exhausted. AOPA members are encouraged to ask their senators to join S. 829 as a co-sponsor of the Medicare O&P Improvement Act (S. 829), and to ask to their representatives to join as a co-sponsor for the House version (H.R. 1530), as well as being a co-sponsor for H. R. 1526, the Medicare Audit Improvement Act. Visit AOPAvotes.org, to access template letters and talking points for all three bills.

HAPPENINGS

RIO 2016

Save the Date for Next Year’s Paralympic Games Preparations are already underway for the next Paralympic Games, which will draw thousands of athletes from across the globe to compete Sept. 7-18, 2016. Highlights will include the following: • Approximately 4,350 athletes from 160 countries are expected to travel to Brazil to compete in 526 medal events in 22 different sports. • Women are expected to make a greater showing in 2016 than in past Paralympic Games; more

than 1,600 females will participate, which is a 10 percent increase from the London 2012 Games. • Canoe and triathlon events will make their Paralympic debut in Rio; each sport will stage six medal events. Clear your schedule now for what is expected to be a spectacular showing of both amputee athletes and competitors with other disabilities.

PEOPLE & PLACES PROFESSIONALS ANNOUNCEMENTS AND TRANSITIONS

Gerald Stark, MSEM, CPO/L, FAAOP, senior upperlimb specialist for Ottobock, has been honored by the American Academy of Orthotists and Prosthetists with its Outstanding Educator Award for 2015. Stark has been active in the prosthetics industry for the past 23 years, during which he has led numerous education and training initiatives and worked in product development as an engineer. He also has served as a contributing faculty member for Northwestern and as a director for the National Commission on Orthotic and Prosthetic Education and the International Society for Prosthetics and Orthotics.

BUSINESSES ANNOUNCEMENTS AND TRANSITIONS

The American Board for Certification in Orthotics, Prosthetics, and Pedorthics (ABC) has published the 2015 Practice Analysis of Certified Practitioners in the Disciplines of Orthotics and Prosthetics. ABC’s Practice Analysis Task Force and ABC Executive Director Cathy Carter worked with Professional Examination Services to create and implement a practice

analysis of ABC-certified orthotists and prosthetists. ABC last conducted a practice analysis study of the orthotics and prosthetics profession in 2006. In 2014, the delineation was revised and the profession was resurveyed to identify changes in the profession related to the delivery of care, technology in use today, and the use of measurable treatment outcomes. The strategy included a validation study to determine current trends in patient care, technology and practice management in the provision of orthotic and prosthetic devices and services by ABC-certified orthotists and prosthetists. The Clearwater Aquarium has offered Camp No Limits a matching grant of $20,000. The camp is designed for young people with limb loss and their families. Donations that are received by May 15 will be doubled via the campaign. Visit the Clearwater Aquarium FirstGiving page website or www.nolimitsfoundation.org. Össur and the Challenged Athletes Foundation® (CAF) have announced a multiyear global sponsorship agreement that continues their collaboration to support people with limb loss. Central to the Össur-CAF agreement is a series of Össur running and mobility clinics presented by CAF, which are held annually across the United States. Six Össur-CAF clinics have been confirmed for 2015, including stops in Washington D.C.; New York City; Tucson, Arizona; Boston; San Francisco, and San Diego, California. Details are available at www.ossur.com/mobility. O&P ALMANAC | MAY 2015

REIMBURSEMENT PAGE

By DEVON BERNARD

The Point of No Return? Billing for refused and returned O&P devices requires a thorough understanding of Medicare’s guidelines

Editor’s Note—Readers of CREDITS Reimbursement Page are now eligible to earn two CE credits. After reading this column, simply scan the QR code or use the link on page 16 to take the Reimbursement Page quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.

E! QU IZ M EARN

BUSINESS CE

CREDITS P.16

MAY 2015 | O&P ALMANAC

it is no longer medically necessary, and the device is deemed refused. Once you are aware that a patient has refused a device by his or her own choice, or the device is no longer medically necessary or needed and can be considered refused, ask yourself three questions to help determine a proper course of action in terms of billing.

Refused Devices

Is the device you were to deliver an off-the-shelf (OTS) item, or is it a custom-fabricated device? If the item is an OTS product, you may not bill Medicare because you may return the item to stock and you may reuse it. However, if the device is an OTS item and you made substantial modifications to it, so it cannot be used with a different patient and cannot be returned to stock, it can be considered a custom-fabricated item for the intent of billing for a refused item.

NE OF THE COMMON questions

posed at AOPA’s coding and billing seminars is how to bill for salvage claims or for items that have been refused or returned by patients. This month’s Reimbursement Page will examine the billing issues related to returned and refused items, and provide some tips and guidelines for these situations.

What constitutes a refused item? “Refused” doesn’t simply mean that the patient doesn’t want to come in for his or her final fitting and pick up the completed item. That is just one scenario that would constitute a refused item. An item, device, or service also may be considered refused if the patient no longer needs it or the item is no longer medically necessary. The change in medical necessity, or refusal, may be the result of a change in a patient’s condition. For example, a physician may have ordered a knee orthosis for a patient, but before you were able to deliver the knee orthosis, the patient and the physician decided the patient needed surgery. Since the patient chose a different means of treatment, the brace may no longer be needed, or medically necessary. The device has now been refused. In another example, a patient may have been ambulatory when the item was ordered, but at the time of delivery the patient has become nonambulatory and a new treatment modality may be required. The original brace is no longer medically necessary and is considered a refused item. In addition, if a patient dies before you are able to deliver the device,

If you were providing a custom device, was the fabrication of the device completed, or were you still fabricating the prosthesis/orthosis when you learned that it was refused and/ or no longer medically necessary? The answer to this question will determine what you are able to bill for and how much you may bill. If you have completed fabrication, you may bill for the complete device—well, almost. You must first determine if any of the parts used in the fabrication may be salvaged and reused. This may be a rare situation, because most parts in a custom device are altered in a way that makes them useful only for one

REIMBURSEMENT PAGE

specific patient. However, if there are parts that can be salvaged and reused, you may not bill for those components. For example, if you are fabricating a below-knee prosthesis (L5301) and you have finished fabricating the prosthesis when you learn of the refusal and you are able to return the foot to the manufacturer for a refund, then you may bill for everything except the foot, because the foot was salvageable. If you are providing a custom device, and you have not finished fabrication when you learn of the refusal, you may bill only for the work that you have completed. For example, if you are fabricating a below-knee prosthesis (L5301) and all you have done is a made a test socket and started to fabricate the final prosthesis when you learn of the refusal, you would submit a claim for the test socket (L5620) and for the L5301 with an estimated cost of the work you completed instead of your customary charge for the L5301. Once again, you must subtract the cost of any parts that may be salvaged and reused because this may not be billed. When did you learn about the refusal? This is one of those rare instances when the date of service is not the physical date of delivery. The date you learned about the refusal, or the date you learned the device was no longer medically necessary, will become the date of service for billing purposes. If the patient has died, the date of service is the date of the patient’s death. If you use a date of service that is after the date of the patient’s death, your claim will be denied. If the patient has truly refused the item and simply will not return to your office for a final fitting, your date of service would be the last day you attempted to deliver the item. Be sure to document all attempts you made to deliver the item. There is no minimum or maximum number of attempts required to declare a device refused, but it is recommend that you make at least three attempts. If the patient still refuses to come in to pick up his or her device, notify that patient of your intent to bill for the item during

one of your last attempts at contact. While it is not required, using a certified letter to inform a patient of your intent to bill will provide documentation, such as a signed receipt of the letter, that confirms that you communicated with that individual about the opportunities to pick up the device and that you are billing for the item.

Photo: Cpl Richard Cave RLC (Phot)/MOD, OGL

Once you have ascertained the answers to these three important questions, and determined that the item has been refused and you have the ability to submit a claim to Medicare, simply submit your claim as you normally would. This would include using any of the modifiers (KX, LT, RT, GA, GZ, etc.) that are required by policy; there are no special modifiers to indicate that the claim is being billed as a refused item or salvage claim. Medicare will process the claim as if the item was delivered normally to the patient. You will want to document in your records that the device was refused, and that is why you don’t have all of the required paperwork on file (e.g., proof of delivery); make sure all of this information is available in case it is requested.

Returned Devices

The guidelines for the handling and billing of returned items, or those items that have been delivered to the patient and the patient has brought back, are a little trickier than the guidelines for traditional refused items. In these situations, you must comply with the supplier standards. Supplier Standard 15 states: “A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.” If the patient tries to return an item, the onus is on you to prove that the item is not substandard and is appropriate for what was ordered, and that the patient was satisfied with the item/service at the time of delivery. Be aware that Medicare always sides with the patient. To help prove an item is not substandard, document all encounters with the patient, including all attempts that you made to make the device satisfactory to the patient’s needs. This documentation should begin with the initial delivery of the item. Consider asking patients to sign the delivery slip, indicating they were satisfied with the item at the time of delivery. If they had concerns, make sure to document those concerns and what you did to address them. If a device cannot be adjusted to satisfy the patient and he or she still returns an item for which you have already received payment, you are under no obligation to make a refund to the patient at the time of the return even if he or she requests that you do so. The only time you must refund the money is if Medicare sends you a formal request for a refund. If you receive an official Medicare request for a refund of a beneficiary-returned item, you must then refund the money; however, you may then appeal the refund, and show that you provided what was ordered and made a good-faith attempt to satisfy the patient. This is where documentation of how you tried to satisfy the patient will come into play. Make sure that your initial order and your final detailed written order clearly indicate what item was ordered; O&P ALMANAC | MAY 2015

REIMBURSEMENT PAGE

this will help to demonstrate (along with your documentation and referring physician’s documentation) that the item provided to patient was “appropriate” for the patient at the time it was ordered and delivered. Finally, it is important that you do not destroy or dispose of the refused or returned device after you have billed for it and received payment for it—at least not immediately. If the patient decides he or she does want the item, or it becomes medically necessary again, you must be able to provide the patient with the device since you already billed and collected payment for that device. If you no longer have the item, you will have to provide the patient with the exact item for which you originally billed, but you will not be able to charge the patient for the second one. Determining how long to retain a refused or returned item before disposing of it is at your discretion. Retaining the device for its useful lifetime would be best, but this may not be practical due to space constraints or other

factors. If you are not able to hold onto the refused or returned item for its useful lifetime, at least hold onto the device for as long you feel is appropriate or until you believe the patient will no longer want the item. For, example if the patient has passed away, you do not need to retain the item for its useful lifetime, and it would be appropriate and safe to dispose of the item after billing. Some practitioners question whether it is acceptable to simply mail the device to the patient—particularly in the case of refused items. This solution is not advisable due to liability issues and concerns. It is better to hold onto the item until its useful lifetime has expired. Remember, even if a device is refused

or returned, you have the right to bill for it. To learn more about the rules regarding billing for returned and refused items, review the Medicare Benefit Policy Manual, Chapter 15, “Covered Medical and Other Health Services,” Section 20.3, “Artificial Limbs, Braces, and Other Custom-Made Items Ordered But Not Furnished.” The manual is available on the Medicare website, www.cms.gov. 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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MAY 2015 | O&P ALMANAC

This Just In

DOC FIX

What ‘Doc Fix’ Means for O&P Repeal of the sustainable growth-rate formula for physician reimbursement paves way for advance of value-based medical care

N WHAT IS BEING hailed by many as the first major legislative accomplishment of the 114th Congress, a bill to scrap the sustainable growthrate (SGR) formula for reimbursing Medicare physicians and replacing it with a longer term solution was signed into law by President Barack Obama last month. The bill, which prevented a 21 percent cut in payments to Medicare physicians, was passed by the House of Representatives by a vote of 392-37 in late March, then was passed by the Senate on April 14, with a vote of 92-8. Although the legislation does not directly affect the O&P profession, it does have several important implications. Here’s why.

Details of the SGR Repeal

The legislation, commonly known as the “doc fix,” replaces a 1990s formula that linked Medicare physician pay to economic growth. That formula proved problematic as health-care costs continuously outpaced economic growth. Though Congress had repeatedly addressed the problem by implementing annual “doc fixes” to avoid physician fee reductions under Medicare, a long-term solution was needed. 18

MAY 2015 | O&P ALMANAC

The new—permanent—“doc fix” formula for physician reimbursement is focused on quality of care. The legislation provides five years of modest but stable payment updates for physicians, which offers some payment stability: Doctors will receive a 0.5 percent bump in each of the next five years as Medicare transitions to a payment system designed to reward physicians based on quality of care. After 2019, doctors will receive bonuses or penalties depending on performance scores from the government, based on the value of care provided. In addition, the law requires means testing of Medicare beneficiaries—so higher-income beneficiaries will pay higher premiums beginning in 2018. The legislation also includes a twoyear extension of the Children’s Health Insurance Program for low-income children and a two-year extension of funding for community health centers. Total cost of the legislation is roughly $210 billion, and remarkably, Congress did not operate under the strict “Pay Go” rules that require dollar-for-dollar cuts elsewhere in government spending to pay the tab. Instead, Congress extracted approximately $70 billion in Medicare savings

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This Just In

to offset some of the costs, including $30 billion in cuts to hospitals over a 10-year period. Those cuts do not specifically impact the O&P fee schedule. While some consumer organizations have expressed concerns that beneficiaries will face greater out-of-pocket expenses and higher Part B premiums, lawmakers said they struck a balance with the legislation. When the bill was passed, Sen. Ron Wyden (D-Oregon), said, “I think tonight is a milestone for the Medicare program, a lifeline for millions of older people. That’s because tonight the Senate is voting to retire the outdated, inefficiencyrewarding, common sense-defying Medicare reimbursement system.” In signing the bill into law, President Obama noted that the legislation will help improve physicians’ quality of care “because it starts encouraging payments based on quality, not the number of tests that are provided or the number of procedures that are applied, but whether or not people actually start feeling better….It encourages us to continue to make the system better without denying service.” The president also lauded the legislation as a “significant bipartisan achievement.”

this does not directly impact O&P services, it is important to know the changes because it will impact healthcare delivery overall,” she says. In fact, the bill encourages better care coordination and chronic care management. It will reward those providers who receive a “significant portion” of their revenue from an “alternative payment model” or patient-centered medical care with a 5 percent payment bonus. A technical advisory committee will be established to review and recommend how to develop alternative payment models and how to measure the quality of care provided. Forward-thinking O&P practitioners may consider ways to get involved in alternative payment models or partnering with other medical professionals in bundled services in anticipation of these changes. (See Editor’s Note.)

Implications for O&P Practitioners

The “doc fix” legislation does not directly affect orthotic and prosthetic providers because O&P claims are not paid according to the physician fee schedule; rather, they are paid according to the fee schedule for durable medical equipment, prosthetics, orthotics, and supplies. But it is significant to O&P professionals for several reasons. First, “The SGR repeal legislation incentivizes physicians to be part of alternative payment models—in other words, more bundling of services,” says Stephanie Kennan, senior vice president of federal public affairs, McGuireWoods Consulting. “While 20

MAY 2015 | O&P ALMANAC

“Physician payments are being comprehensively changed,” says Michael Park, a member of Alston & Bird’s health-care legislative and public policy group. “We should be vigilant in monitoring the effects on other stakeholders, such as the O&P community.” In terms of physicians being more accountable for their quality of care as well as their costs, “there could be downstream effects for other stakeholders,” he adds. In addition, Kennan and Park note there may be a positive side effect of the new law in that O&P may no longer be in the spotlight as a sector of health

care that should be targeted for cost reductions. “Many health-care policies were driven by how much savings could be derived in order to pay for the annual need to ‘fix’ the SGR temporarily,” Kennan says. “No longer having that incentive driving policy means that O&P services are not in the bullseye to pay for physician services.” “The perennial threat of Medicare cuts to the O&P community to pay for a temporary doc fix is over,” adds Park. Joe McTernan, AOPA’s director of reimbursement services, also notes there is a “silver lining” to the repeal of the SGR: “The fact that a deeply divided Congress was able to work together to permanently fix a problem that everyone agreed needed to be fixed in order to continue to provide open access to physician services for Medicare beneficiaries provides hope that legislation is a potential avenue to solve some of the longstanding problems that exist within the Medicare program,” he says. This achievement increases the likelihood that O&P-related bills advocated by AOPA and the O&P Alliance may have a chance of making it out of gridlock. With several pieces of legislation recently introduced, including the Medicare O&P Improvement Act of 2015 and other smaller pieces of legislation that provide relief for practitioners bogged down by Recovery Audit Contractor audits and excessively long appeals processes, this is good news, indeed. AOPA and its lobbying team are working hard to have legislation introduced that would exempt O&P services from “acute-care bundling” schemes. Editor’s Note: Watch for the June issue O&P Almanac Leadership Series installment in which we investigate how O&P professionals can partner with hospitals and institutional networks to ensure they are part of the health-care solution in alternative payment systems.

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COVER STORY

Weighty Issues Need to Know:

overweight pediatric patients for Blount’s disease can be • Many • Treatment have special needs, and research shows complicated, and a specially designed that children with Down syndrome, spina bifida, Prader-Willi syndrome, and development coordination disorder are at greater risk for becoming obese.

a walking routine for • Maintaining children with spina bifida can be chal-

lenging. Braces must be adjusted or replaced every few months due to growth, and patients typically choose to walk less and use wheelchairs more. Custom AFOs and KAFOs can help.

overweight scoliosis patients, it • For can be “more difficult to obtain a

good purchase on the pelvis and also to ensure that the orthoses are being donned correctly each time when landmarks are not visible and may even be difficult to palpate,” says one source. Issues of cosmesis and bracing compliance also must be addressed.

MAY 2015 | O&P ALMANAC

Blount KAFO with an optionally locked hinged knee may help the patient become accustomed to the orthosis during the early stages of treatment.

or obese children also may • Overweight have painful flat feet that tire easily, preventing them from walking long distances. Many orthotists have fit these patients with foot orthoses to redistribute the weight more evenly.

COVER STORY

As more children present with obesity, orthotists must adjust treatment protocols to ensure optimal outcomes for a number of pathologies By CHRISTINE UMBRELL

RTHOTIC TREATMENT OF CHILDREN requires both clinical

expertise and sensitivity—even more so for patients who are overweight or obese. These skills are needed now more than ever: Childhood obesity has more than doubled in children and quadrupled in adolescents during the past 30 years, according to the Centers for Disease Control and Prevention (CDC). Children and adolescents who are obese are at greater risk for bone and joint problems, according to the CDC. And obesity has been associated with an increased risk for several musculoskeletal conditions in children and adolescents, including Blount’s disease, genu valgum, and idiopathic scoliosis, according to research published in Clinical Orthopedic and Related Research. “In some ways, treating obese pediatric patients is definitely more challenging than adult obese patients. Pediatric patients in general are harder on their orthoses running and jumping while they play, and the added weight can start to stress the materials more quickly,” says Chrysta Irolla, MSPO, CPO, of the University of California, San Francisco. “For many of the progressive pediatric pathologies, obesity increases the energetic cost of walking significantly enough to eliminate their ability to ambulate independently and force them into a wheelchair at an earlier age.” Whether patients enter the orthotist’s office due to conditions caused by their weight, or are being treated for a problem unrelated to their weight, it’s important to understand how to treat this patient population for optimal outcomes.

O&P ALMANAC | MAY 2015

COVER STORY

Developmental Delays

Many of the overweight patients who enter orthotists’ facilities are children with special needs, some of whom are more prone to obesity than other pediatric populations. For example, research has shown that children who have Down syndrome, spina bifida, Prader-Willi syndrome, and development coordination disorder are at greater risk for becoming overweight or obese.

Josh Ahlstrom, CPO

“There are certain diagnoses where children are prone to being more sedentary,” says Josh Ahlstrom, CPO, clinical practice manager at Midwest Orthotic & Technology Center. “Children with hypotonia—low muscle tone—typically have a difficult time maintaining core stability and utilizing their strength in appropriate pathways, which can lead to developmental delays and inefficient gait patterns.” Not only is it more difficult for these patients to ambulate, but they also may hamper their own abilities to

lose weight by choosing to be inactive. “Kids are very smart, and they adapt very quickly. Just as adults, they are more apt to choose activities that they are more proficient in—where they can win. Children with hypotonia will often do puzzles, read books, and play board and video games—activities they can do as well as their peers, but not necessarily activities that will promote movement.” And less activity feeds a vicious cycle of excess weight. For patients who are born with developmental delays, early intervention is key. “If we catch them early, between the ages of one and two, then they won’t be too heavy for flexible lightweight materials, and we’ll have our whole tool set available” for orthotic intervention, says Ahlstrom. “We never want to over-brace kids. We must evaluate their skill sets and needs and help them become more independent and functional over the course of time.” Providing such patients with devices that allow them to use their bodies effectively is important, says Ahlstrom. “You need to make sure their foot is in good alignment, but you should allow them to develop their strength,” he says. “The brace should help provide better alignment to the body as a whole, and encourage them

U.S. Childhood Obesity Fast Facts • The percentage of children ages 6 to 11 who were obese increased from 7 percent in 1980 to nearly 18 percent in 2012. • The percentage of adolescents ages 12 to 19 who were obese increased from 5 percent in 1980 to nearly 21 percent in 2012. • “Overweight” is defined as having excess body weight for a particular height from fat, muscle, bone, water, or a combination of these factors.

MAY 2015 | O&P ALMANAC

• “Obesity” is defined as having excess body fat. • Obese youth are more likely to have risk factors for cardiovascular disease, such as high cholesterol or high blood pressure. • Children and adolescents who are obese are at greater risk for bone and joint problems, sleep apnea, and social and psychological problems. Source: Centers for Disease Control and Prevention

to use their own muscles to develop better motor plans.”

Spina Bifida

Children with spina bifida comprise another segment of patients who frequent O&P facilities. Obesity is an epidemic among this group: There is a 50 percent chance that children with the condition will become overweight after age 6, and 50 percent of adolescent patients are obese, according to the Spina Bifida Association. Weight gains are common due to a gradual decrease in physical activity. Orthotists who work with these patients are “fighting a cycle of a sedentary lifestyle, where food is often given as a reward or serves as a means of immediate gratification,” says Janet Marshall, CPO, LPO, who has extensive experience treating spina bifida patients at Shriners Hospital for Children in Tampa.

Janet Marshall, CPO, LPO

Marshall notes that it can be challenging to maintain a walking routine as these children grow. Braces must be adjusted or replaced every few months due to growth, and patients typically choose to walk less and use wheelchairs more. “Often between the ages of 2 and 9, the use of reciprocating gait orthoses decreases from a few hours of wear time per day to a couple of times a week at therapy,” Marshall says. Marshall suggests that custom AFOs can be useful in evenly distributing weight so the heel is not taking the full brunt of impact. She also recommends shock-absorbing cushions on the plantar surface as well as valgus or varus pads to maintain proper alignment and reduce skin breakdown. Keeping spina bifida patients mobile is important because they need to have the strength and ability to, at a minimum, transition from wheelchair to bathroom to bed, says Marshall.

COVER STORY

Ahlstrom says he tries to avoid using floor-reaction AFOs for young spina bifida patients, because these devices “lock them up and rob patients of their proprioception,” he says. “There has to be some movement available so they can go through specific stretch reflexes.” Instead, he often fits young children with lightweight flexible supra malleolar orthoses (SMOs), which offer a more midline stable position while enabling function. Regardless of the type of orthosis, fitting these patients can be difficult: “An increase in adipose tissue creates challenges when using an external device that is intended to hold precise bone and joint position, which is buried further beneath soft tissue,” says Gabriel Beversluis, CO, of Pediatric Orthotic Specialists in Michigan. When treating such patients, “less padding is needed when more

soft tissue is already present,” says Beversluis. “Too much padding can lead to less precise control of the bones and joints.”

Gabriel Beversluis, CO

therapists to quickly add on the knee joints and thigh section for standing and walking at any point throughout the day without having to remove shoes or pants,” Beversluis explains. This modification makes it much easier for patients to become mobile several times throughout the day.

Scoliosis

He has found a simple solution that has made a significant improvement in the quality of life and promoted increased activity levels for overweight spina bifida patients, who typically spend most of their day in a wheelchair: “We are using quickdisconnect mechanisms within these patients’ KAFOs. This allows patients to wear the AFO section full time, and makes it easy for parents and

Bracing treatments for scoliosis have been found to be significantly less effective for heavy teenagers, according to a recent study conducted at Johns Hopkins Children’s Centers. The study found that overweight teenagers were 2.5 times more likely to have scoliosis curvatures that progressed despite wearing a brace; only 29 percent were treated successfully, and 44 percent eventually needed surgery to correct spinal curvature. “The more soft tissue you have to push through, the less force you’re going to be able to apply to correct the curvature,” says Todd DeWees, CPO, of Shriners Hospital in Portland.

Todd DeWees, CPO

Beversluis points to the significant flaring on a mold, where an abundance of soft tissue might otherwise create pinching of the skin.

MAY 2015 | O&P ALMANAC

And with overweight scoliosis patients, it can be “more difficult to obtain a good purchase on the pelvis and also to ensure that the orthoses are being donned correctly each time when landmarks are not visible and may even be difficult to palpate,” adds Beversluis. Some orthotists have found small ways to increase the chances of curvature correction with overweight patients. Beversluis notes he adjusts fabrication techniques because more pressure is needed to prevent migration of the TLSO. “Trimlines may have soft tissue spilling over, which may require more adjustability. We fabricate TLSOs with overlapping padding and components that attempt to accommodate increased or decreased girth of the trunk,” he says.

COVER STORY

Mark Holowka, MSPO, CPO, LPO

At Children’s Healthcare of Atlanta (CHOA), clinicians use CAD/CAM to scan scoliosis patients “because we get a much better fit,” says Mark Holowka, MSPO, CPO, LPO. Cosmesis issues also come into play, says Marshall. “You’ve got to work with what you’ve got, and the patients have to tolerate it. It’s not flattering when there is a lot of tissue that pushes above the brace. It can be embarrassing, and hard to conceal.” “For teenage patients who are developmentally normal with pathologies like scoliosis, there is often a level of self-consciousness about being overweight, which makes them less accepting of orthotic interventions that add extra bulk or draw more attention to them,” says Irolla. Teenagers who are focused on vanity issues may require alternative treatment plans, such as nighttime bracing protocols for overweight patients, since “a greater corrective force can be exerted when the patient is supine,” says Irolla. Adds DeWees: “With nighttime bracing, patients will be able to wear their spinal orthoses at the prescribed tension and at the prescribed hours-perday, which will improve outcomes.”

rotation. But the design of a Blount KAFO may include a hinged knee component that can be optionally unlocked to permit flexion,” he says. This may help the patient become accustomed to the orthosis during the early stages of treatment. “A free knee at certain times of day also may improve compliance in bilateral cases while still permitting maximum correction with a locked knee at night.” Children who are overweight or obese also may have painful flat feet that tire easily, preventing them from walking long distances. Many orthotists have fit these patients with foot

orthoses, due to “the need to distribute the greater mass, more evenly, across the foot that is collapsing under the increased weight,” says DeWees. Flat foot can be a challenge to treat due to the amount of pressure created within a foot orthosis, says Beversluis. “With obesity-related flat foot, often there seems to be less of the hindfoot eversion and forefoot abduction and more pure midfoot dorsiflexion, which requires a foot orthosis with more significant pressure into the longitudinal arch to address. This pressure is also increased with the increase in weight.”

Blount’s Disease and Flat Foot

Blount’s disease, or severe bowing of the legs, is a condition in which the inner part of the tibia fails to develop normally. Late-onset Blount, which develops at ages 4 to 10, and adolescent Blount are more commonly associated with obesity than infantile Blount. Treatment can be complicated. “In Blount, the coronal correction of the orthosis is most effective with the knee fully extended,” says Nicholas LeCursi, CO, director of research and development for Becker Orthopedic. “Knee flexion under a corrective valgus stress couples transverse plane O&P ALMANAC | MAY 2015

Fabrication and Material Considerations

EGARDLESS OF WHETHER A

patient’s condition has been caused by his or her weight, or weight is just a coincident factor, orthotists must determine the appropriate componentry for best outcomes. “Devices need to be durable, but not so heavy that it’s a disincentive to activity,” says Todd DeWees, CPO. Breakage and material failures are prevalent among these patients. “It’s a catch-22,” says Mark Holowka, MSPO, CPO, LPO. “How strong can you make a brace so it holds up, without getting in the way of function?” At Children’s Healthcare of Atlanta, staff are constantly on the lookout for lighter, stronger materials that also offer adjustability since they will need to be modified as children age. “Kids are still growing, and the typical adult materials that are known for being durable and lightweight—such as prepreg carbon fiber and other carbon technologies—are hard to adjust,” he says. One recent breakthrough has been the arrival of plastics that are embedded with carbon braiding, which offers improved strength without sacrificing compliance, says Holowka.

MAY 2015 | O&P ALMANAC

Chrysta Irolla, MSPO, CPO, tries to reinforce the structural integrity of orthoses for overweight patients by adding corrugations to increase the rigidity of a plastic strut, adding polypropylene prepreg reinforcements, using heavier-duty joints, adding carbon fiber foot plates to reinforce stirrup attachment points, and using a molded inner boot as an extra layer of total contact control. “In general, there needs to be increased contact and/or increased rigidity to provide the necessary control of the additional weight,” she says.

Chrysta Irolla, MSPO, CPO

Though it might seem that overweight kids naturally require stronger components than normal-weight children, Nicholas LeCursi, CO, notes that it’s a more complicated decision, especially “when you consider the forces that can result from spasticity,” he says. “Planes of control impact the shape of the component and bars as well as the orthosis. Increased rigidity of the orthosis and high activity levels can shorten the service life of a component. It’s also important to balance the ambition of treatment with the reality of what the patient and family can handle.” Signification modification may be required. In some cases, DeWees adapts adult devices to fit pediatric patients, and in other cases he adapts pediatric components to accommodate a wider circumference. “If you’ve got one parameter that fits well—for example, a length on a pediatric

device that’s appropriate, but not the circumference—you can modify the nonfitting parameter,” DeWees says. “You need a lot of creativity with this patient population.”

Nicholas LeCursi, CO

Gabriel Beversluis, CO, fabricates custom KAFOs, AFOs, and TLSOs in house to accommodate the modifications needed for overweight patients. “We have to consider making larger flares around the edges of custom plastic orthoses to prevent pinching or tissue irritation along trim lines,” he says. “We adjust the amount of padding that might be needed if there is significant soft tissue already present. For AFOs, we use less padding around the foot and ankle. We might also create more pressure into the soft tissue around bony prominences to maintain the necessary relief at the bony prominence. And we give greater instructions to parents to make sure AFOs are donned in the ideal position.” Similarly, LeCursi notes that excessive redundant tissue may decrease contact pressure by increasing contact area at the orthotic interface, but soft tissue also may increase the focal pressure along a trimline. “For this reason, one common feature in orthoses for overweight kids is a flared trimline or a liner that extends past the trimline to soften it,” he says. “Coupling the corrective force to the skeletal system also may seem to be more challenging. Aggressive correction in the orthosis to accommodate compression of the soft tissues may help regain some of the corrective force.”

Sports Injuries and Long-Term Implications

Not all overweight patients are inactive. “The majority of my obese kids are otherwise typical children in middle or high school who have had an orthopedic injury related to their body weight,” says DeWees, who sees a number of patients for knee and foot injuries that have occurred when children have tried to participate in a sport and are not conditioned properly. With this population, the patients are bigger, which “puts higher forces on joints and bones,” says Holowka. The goal of the orthotist is to design a device that will keep the patient active. For these patients, component selection is the key to proper orthotic intervention. (See “Fabrication and Material Considerations” on page 28.) Another important consideration in treating overweight patients is the long-term impact in the context of children’s level of musculoskeletal development, activity level, and tolerance for orthotic treatment, says LeCursi. In addition to the clinical problems overweight children typically experience today, there may be issues that present 20 or 30 years in the future. “We have to consider the idea of cumulative trauma,” says Holowka. “Overweight children experience increased moments at their joints; their angles change; there’s gait compensation. So in the long run, the assumption is that they will have more joint problems, more knee, hip, and low-back problems. At this time, we don’t know the extent of the damage this will cause.”

Talking About Weight

Though it can be uncomfortable to discuss patients’ weight, orthotists have a responsibility to start these difficult conversations, with both patients and families. “The most challenging patients are the ones who don’t want to admit they have a weight issue,” says DeWees. In such cases, it’s important to try to get patients to accept treatment, and to accept referrals to other health-care providers who can help with the

Early Intervention for Developmental Delays Some children who have developmental delays can benefit from bracing as Anne Paré, CO, LO soon as they start becoming mobile. Pediatric patients with low muscle tone and excessive pronation are slow to meet developmental milestones. But catching them early can help ensure an improved gait once they hit elementary school and beyond, says Anne Paré, CO, LO, who has extensive experience treating toddlers with development coordination disorder, Down syndrome, general hypotonia, and developmental delays. “We start them in braces when they pull to stand so knee and hip alignment is appropriate,” says Paré, a clinician at Hope Orthotics and a clinical research and education consultant for SureStep. She often fits young patients with lightweight flexible supra malleolar orthoses (SMOs) that are designed for hypotonia. These types of braces “don’t interfere with crawling, walking, or running, but they still allow development of the muscles, proprioceptors, and balance reactions, and help children stay on track for a heel-toe pattern of walking and an energy-efficient gait,” says Paré. Though braces can’t fix patients’ pronation or low muscle tone, they can be useful in helping patients develop successful gait patterns. With early intervention, many of Paré’s patients are out of SMOs by the age of 5, once their gait pattern is well established.

underlying problems associated with excess weight. Clinicians at larger facilities and educational institutions typically have access to a number of resources to pass on to patients to promote healthier lifestyles. For example, at Shriners Hospital in Portland, DeWees works closely with staff physical therapists and nutritionists. And at CHOA, staff have created a website, strong4life.com, that promotes a wellness movement designed to reverse the epidemic of childhood obesity in Atlanta. Not all orthotists have such extensive access to specialists and parental resources, but even those practitioners in private practice can develop relationships with outside sources to

help treat the whole patient—not just one aspect of that patient’s health. Ultimately, the best advice for treating overweight patients is to look closely at the individual—not his or her size or condition. “No two children are exactly the same, even if they have the same condition, so you have to continue to be creative to achieve successful outcomes with children,” says Ahlstrom. “When you help a child gain more independence, you help a family gain independence, which is a very powerful thing.” Christine Umbrell is a staff writer and editorial/production associate for O&P Almanac. Reach her at cumbrell@ contentcommunicators.com. O&P ALMANAC | MAY 2015

By ADAM STONE

A Policy Forum

for All Ages

Armed with hard data, experienced professionals and students flocked to educate legislators about the value of O&P care

HEN MORE THAN 120 O&P advocates gathered in Washington, D.C., March 23-25 for the annual AOPA Policy Forum, they came with more than just the usual round of concerns. Certainly they were eager to educate legislators about Recovery Audit Contractor (RAC) audits, competitive bidding, judicial delay, and other pressing issues. But they also came ready to share data—in the form of a brand new study commissioned by AOPA and carried out by noted health research firm Dobson-DaVanzo. This significant new document shows how better practices by CMS could generate significant cost savings for the government, including more than $10 million that would be saved by resolving the overwhelming backlog of administrative law judge (ALJ) hearings. In addition to hard data, attendees came with another arrow in their quiver. This year, more than a dozen O&P students signed on to lobby—a generation of rising practitioners eager to convey the profession’s messages to their lawmakers. Before setting out to meet with more than 139 lawmakers, participants were briefed on a range of urgent concerns.

MAY 2015 | O&P ALMANAC

AOPA Past President Thomas Kirk, PhD

Above, AOPA Members Being Briefed for Hill Visits Left, Michael Park of Alston & Bird, AOPA Legislative Counsel Sen. Chuck Grassley (R-Iowa)

Hard Data

Attendees heard first from Rep. Brett Guthrie (R-Kentucky), who urged O&P professionals to humanize their message to legislators. He encouraged them to have patients tell their own stories and to discuss how the various rules impact their practices. “When people tell about themselves, that’s what I like to hear,” he said. “We’re all human beings.” AOPA has had its best legislative success in the past when patients themselves have helped to tell the story, so the presence of so many O&P patients during Advocacy Day may well have helped to tip the scales. The fact is, legislators cannot realistically hear from every constituent on every issue. That’s why AOPA’s efforts to bring actual patients to the table carries so much weight. As Representative Guthrie suggested, Congress can best be swayed by the first-person accounts of how policy impacts those in greatest need of care.

AOPA Past President Thomas Kirk, PhD, was the first to broach the subject of the Dobson-DaVanzo study, a topic that speakers would return to throughout the briefing session. With hard data in hand, “it changes the way you should think about yourselves,” he said. Research helps demonstrate that “what you say is absolutely the truth.” The study reinforces the argument being made by the O&P community’s initiative Mobility Saves, which has been working in recent months to demonstrate the cost-effectiveness of O&P, as well at the improvement in patients’ quality of life. “We are bringing value, not just cost. That’s what Mobility Saves is all about,” Kirk said.

Range of Issues

Against this backdrop of big savings and hard data, a number of O&P leaders launched into a powerhouse overview of the issues pressing down on the profession.

Rep. Brett Guthrie (R-Kentucky)

O&P ALMANAC | MAY 2015

Fresh Perspectives

articipants at the AOPA Policy Forum trended a bit younger this year, as a large group of O&P students came to this year’s event to lobby on behalf of O&P. By adding their voice to the mix, the practitioners-to-be played a hand in determining their fates. The students “bring a fresh perspective,” says Jonas Ljung, MSPO, BEPO, who helped organize the student participation. “They haven’t been fighting the same battles that other practitioners have been fighting for 20 years, so they bring new ideas and they bring a fresh approach.” The field stands to gain, he says, when fresh participants speak up on the critical issues of the day. A practitioner with Nascott Orthotics and Prosthetics in Washington, D.C., Ljung worked with the National Commission on Orthotic and Prosthetic Education to bring

Paula Gomez St. Petersburg College

a 14-strong contingent of students to Washington. “Legislation is very important to orthotics and prosthetics; it’s a field that often is overlooked, so the more voices that are talking to the senators and congressmen, and the more different types of voices, the more recognition the profession gets,” he says. The students outperformed expectations at the event: “The biggest surprise was how well prepared the students were, and how comfortable they were being put in these situations,” Ljung says. “They were very well versed on the issues, even before they came to the Forum, and that made it very easy for them to talk to the staffers and the lawmakers.” Here, several of the student participants reflect on their day on the Hill.

As she prepares for a summer graduation, Paula Gomez says she knew little about the legislative side of O&P prior to the Policy Forum. “I had no idea about anything that had to do with policy or legislative issues. I knew there were things like RAC audits, but I didn’t know how many were happening or what impact they were having,” says Gomez, a St. Petersburg College student pursuing her degree long distance at Florida State University. “It was an eye-opening experience,” she says. Her group was scheduled to meet with Florida lawmakers including Sen. Bill Nelson (R), Sen. Marco Rubio (R), Rep. Richard Nugent (R), Rep. Gwen Graham (D), and Rep. Ted Yoho (R). “They clearly don’t have the time to listen to all of our issues, and it was all a rush at times, but they were all nice and the clearly paid attention,” she says. Just as valuable was the time spent with her O&P colleagues. “This is a very small field, and I got to meet a lot of people who care about the field, people who I admire, who I think of as my mentors,” she says. “It also meant a lot to me to meet the other students from the other programs, to see that they are going through the same process, wanting to learn about these same issues.”

MAY 2015 | O&P ALMANAC

Katy Blaharski Eastern Michigan University

“I had a fantastic time,” says Katy Blaharski, who is just wrapping up her studies at Eastern Michigan University. “Up until now I wasn’t fully aware of what was going on in our field, why things happen the way that they do— RAC audits and billing and insurance. So this was really eye opening.” When Blaharski heard about the opportunity to join the Policy Forum, she jumped at the chance to get an inside look at the forces driving her profession. “I was really curious as to how things worked, especially how politics impacts our field. I know that it does, but I wasn’t really sure how, and to what extent,” she says. Blaharski says she was especially impressed by the turnout at the Forum. “I was pleasantly surprised that there were so many practitioners willing to go there and fight for our field. It was really exciting to see that many people being that passionate about what we do,” she says.

Kimberly Champion Alabama State University

For Kimberly Champion, going to Washington, D.C., meant getting the real deal. “We hear a lot about the issues going on in the field, and I wanted to get the information straight from the source and not just from the different practitioners you hear talking about it,” says Champion, who plans to graduate from Alabama State University this spring. She admits to being a little awed by her first experience in D.C., and her first visit to the nation’s legislature. “I thought I knew what it would be like, but when you get there and you walk up to this building, it’s impressive. You just know that it is important,” she says. Champion’s group was slated to meet with Alabama’s congressional members: Sen. Jeff Sessions (R), Sen. Richard Shelby (R), Rep. Terri Sewell (D), Rep. Martha Roby (R), and Rep. Mike Rogers (R). “Every meeting was different, every staffer I met with had different questions and was concerned about different things,” she says. “No one seemed to follow the same routine.” One aide understood health care from a university point of view, while another who worked for a senator on the appropriations committee was all about the money. “This was my first experience seeing the whole big picture, and that made it a big learning experience,” she says.

Nick Sellas University of Pittsburgh

As he prepares to graduate this spring from the University of Pittsburgh, Nick Sellas looked to the Policy Forum as a chance to extend his impact. “We all got into this field because we want to help people, and this seemed like an opportunity to do that on a grander scale, to have an impact on all of the patients, not just the ones that I am seeing at any given time,” he says. The team had appointments with Pennsylvania’s Rep. Patrick Meehan (R), Rep. Michael Fitzpatrick (R), Sen. Bob Casey (D), Rep. Brendan Boyle (D), Rep. Robert Brady (D), and Sen. Pat Toomey (R). “We were very well received,” he says. “I think we are still a little bit unknown as part of the medical field; people don’t know what we do or how we do it. So we have to tell people how we really impact people’s lives. Every time we were able to get that message across to them, we were well received. But we do have to paint this picture for them, before we can even ask them to do something.” Sellas says the student contingent played an important role in this year’s Forum. “We are the future of the field. A lot of the people in that room are going to be retiring, and that torch needs to get passed on. This is a way for the students to get our feet wet, to begin to really establish ourselves,” he says. “Ultimately, everything we did there is for the patient. This is so that we can do our jobs, which is to always work for their betterment.”

AOPA Executive Director Thomas Fise, JD, delivered a warning about the evolving situation regarding off-theshelf (OTS) orthotics and the continued expansion of the definition of the term “minimal self-adjustment” through policy-based channels rather than the notice and rule-making process required by the Administrative Procedures Act. AOPA believes that CMS has set the definitions too broadly, and is circumventing due process by allowing the DME MACs to establish policy that further expands the types of orthoses that can be considered OTS and therefore be subject to inclusion in future rounds of competitive bidding. While there is pressure building to appropriately define terms using the required notice and rule-making process, it is far from clear how the situation will play out.

AOPA Executive Director Thomas Fise, JD

O&P has tried to pin down rulemakers numerous times on this issue, “and just when you think you have figured them out, they throw you a curve ball,” said Joseph McTernan, AOPA’s director of coding and reimbursement services. The litany of challenges continued. Michael Park, AOPA’s legislative counsel from Alston & Bird, briefed participants on acute care bundling, a proposed effort to reduce medical costs by redistributing compensations. It is an effort AOPA opposes, and the association has made some headway in keeping O&P out of bundling legislation. AOPA is working on legislation to be introduced in the House of Representatives that would specifically exempt O&P from bundling schemes.

O&P ALMANAC | MAY 2015

Meet the Voices of Authority Among this year’s attendees were dozens of seasoned professionals who are repeat participants, including practitioners and others advocating on behalf of patients.

Victor Bustamante, LPO Mid Florida Prosthetics & Orthotics

Why did Victor Bustamante, LPO, attend the Policy Forum for the fourth time this year? “With the state of our field, knowledge is power,” he says. “Every time I go there I get a better understanding of what is happening, what things are being discussed on Capitol Hill that will affect us down the line. I want to get as much knowledge as I can. You can’t bury your head in the sand.” Reflecting on his visits with legislators, Bustamante says he was especially glad to have in hand the findings of the new DobsonDaVanzo study. “For us, it made a real difference: Data can’t be argued,” he says. “It gives your argument credibility when it’s not just us pontificating on our issue. It gives the argument validity, and that is key—when you can prove what you are telling them.” Bustamante’s team had appointments in the offices of Senator Nelson and Senator Rubio as well as Representatives Graham, Nugent, and Yoho. He scored big on face time, getting past the usual front line of staffers to make the case for sensible O&P legislation in front of two actual lawmakers: Representatives Graham and Yoho. “That was more than I have ever had an opportunity to see before,” he says. “It was my best personal experience there. They were very engaged. It really did feel like we were being heard.” Given the opportunity, he honed the message down to the basics. “Our story is a simple story. It doesn’t take a rocket scientist to figure out that things like the RAC audits are unjust,” he says. 34

MAY 2015 | O&P ALMANAC

Eric Ramcharran, CPO Hanger Clinic, Tallahassee, Florida

Eric Ramcharran, CPO, had a great day on the Hill, also making his case in the offices of Senator Nelson and Senator Rubio, as well as Representative Graham and Representative Yoho. “They all took the time to listen to us, and they understood our problems,” he says. “They were all very willing to sit and talk. They accepted the pamphlets we handed them, along with copies of the present bills. One of them even said it’s a no brainer,” Ramcharran said. Ramcharran stresses the importance of the Policy Forum as a rare moment for the entire O&P profession to speak with one voice. “With all of the changes that are happening at the government level, the things that trickle down to us, especially in terms of CMS and how we get paid, it really affects everybody,” he says. “Our field is really small. Our voices don’t tend to get heard. So I wanted to be there to educate our lawmakers.” He says he was especially pleased to see a large student contingent taking part in the Forum. “To me it was great to see them wanting to get involved. I am on the far side of the slope: This is their field now, and it’s great to see them want to fight for what they believe, and to fight for their patients,” he says.

Scott Williamson, MBA Consultant, Quality Outcomes

As an outside consultant to the senior living industry, Scott Williamson, MBA, brought to the AOPA Policy Forum a neutral stance he hoped would resonate with lawmakers. “I have no direct financial interest in this. I am there only as an advocate for the patients because they are the ones who get harmed by poor policy; they are the ones who get harmed when practitioners can no longer stay in business,” he says. “So I can speak the language of the lawmakers, without being seen as having that direct self interest.” AOPA representatives did a good job expressing their concerns to lawmakers, outside the sometimes unresponsive venue of CMS discussions, he says. But there still is much to be done. “The real work happens at home in the follow-up, the relationships you create with that politician,” he says. “You can’t just shake hands and say a few nice things. You have to keep at this. You have to have community events so that these politicians can meet their constituents, so that they can humanize this whole thing.”

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Above, left to right: Michael Oros, CPO, FAAOP; AOPA President Charles H. Dankmeyer Jr., CPO; Sen. Grassley; Sam Liang, MBA; James Campbell, PhD, CO, FAAOP Left to right: Thomas Fise, JD; James Campbell, PhD, CO, FAAOP; Michael Oros, CPO, FAAOP; Sen. Grassley

Rep. Mark Meadows (R-North Carolina)

Stephanie Kennan, with AOPA’s legislative counsel from McGuireWoods Consulting

Dan Ignaszewski, director of government relations and marketing at the Amputee Coalition

MAY 2015 | O&P ALMANAC

Several experts, including Peter Thomas of Powers, Pyles, Sutter, & Verville, and Brian Looser, AOPA’s legislative counsel from McGuireWoods Consulting, spoke on the troubling ALJ process, where practitioners can appeal RAC findings. They reviewed the interminable delays now up to three years that are preventing O&P practitioners from getting redress from unfair RAC findings, as well as the halting efforts so far to get these delays under control. All of this, in turn, fed into the Dobson-DaVanzo findings: RAC auditors claim the government has been underpaid. They seize the difference, tying up the money for years while the practitioner awaits an ALJ hearing. When the practitioner wins the appeal, as is often the case, the government has to repay the money—with interest. The Dobson-DaVanzo research shows for the first time just how much the government loses on this deal. In 30 months, accumulated interest payments on successful appeals reached $139,923, or about 21 percent of the remaining recouped funds. That’s a big bite and one that could be prevented if practitioners were simply allowed to hold onto their money until after an appeal had been won or lost. As the briefing wound down, it became clear that O&P has its allies in Congress. Rep. Mark Meadows

(R-North Carolina) recalled first hearing about the RAC audit situation. “I said, ‘This can’t be fair and it can’t be right. There must be a misunderstanding,’” he said. But that’s how it goes sometimes in Washington. “Things are not always what they seem. It can always be a little worse.” Representative Meadows encouraged the attendees to speak with a strong voice, and congratulated them on their efforts to get their story heard among lawmakers. “I think it’s time they feel the heat,” he said. “Do not underestimate the value of what you are about to do.” He also put his words into action with the introduction of H.R. 1526, the Medicare Audit Improvement Act of 2015, which specifically limits recoupment, prior to the completion of an ALJ review, to no more than 50 percent of the denied claim’s value. Those in attendance heeded the congressman’s words when they made direct contact with legislators. Armed with briefing materials on all the pressing O&P legislative issues, they travelled the Hill in groups, visiting lawmakers from their home districts, pressing home the case for smart policy that serves the patients’ interests. Adam Stone is a contributing writer to O&P Almanac. Reach him at adam. stone@newsroom42.com.

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O&P ALMANAC | MAY 2015

MEMBER SPOTLIGHT

Grace Prosthetic Fabrication Inc.

By DEBORAH CONN

Changing With the Times Florida fabricator caters to patients’ evolving needs

D GRACE’S ENTRY INTO the

MAY 2015 | O&P ALMANAC

are not as popular anymore and orders slowed down since Medicare stopped paying for cosmetic skins.” More high-tech add-ons are available through a subsidiary of Grace Prosthetic Fabrication, called Grace-FX, which serves the automotive industry as well as O&P. One, hydrographic printing, used by the military for camouflage, creates a long-lasting decorative finish on prostheses in a wide range of colors and patterns. The Grace Prosthetic Fabrication team With a technology called Gator Glass Illumination, amputees can may call in measurements, send wear a device decorated with in a cast, or fill out a form availan emblem or design that, when able on the company’s website. switched on, will light up. “We are In addition to fulfilling orders the only central fab in the country from O&P practitioners, Grace FACILITY: with a license to provide Gator Prosthetic Fabrication offers Grace Prosthetic Glass,” says Grace. “Patients love it. products it has developed on its Fabrication Inc. We get a lot of people who choose own. The Grace Plate, a four-hole college emblems and then light round socket adapter plate, “has OWNERS: them up at games. become the most popular attachEd Grace and “When I first got into the field, ment plate out there,” says Grace. Tony Culver amputees wanted devices that “I came up with the idea because looked like natural limbs. That has it allowed us to align the plate totally changed, and now lots of after the socket was fabricated.” people who wear prostheses want to The plate led to the developbling them out and show them off.” ment of an accompanying lock, Grace believes the high quallanyard system, and offset plates for alignment. “We’re always ity of his products is the key to trying to think of other things we his company’s success. “We Ed Grace and Tony Culver can come up with,” says Grace. make sure things are right before The company also offers the they leave the plant. And we Articulating Grace Gauntlet, a have a fabulous turnaround, just LOCATION: handmade ankle-foot orthosis that three to four days in-house.” New Port Richey, provides firm support but allows Grace may have ended up Florida the user to move naturally, says in O&P fabrication by accident, Grace. Another version, with a but he has never looked back. HISTORY: toe filler, accommodates amputa“This has always been easy for 25 years me,” he says. “I fell into sometions and is worn with a shoe. Clients can order devices with thing I was born to do.” spray-on cosmetic skins. “We have about 32 different skin tones and we Deborah Conn is a contributing can even create the illusion of hair writer to O&P Almanac. Reach her or a tattoo,” says Grace. “But they at deborahconn@verizon.net.

PHOTOS: Grace Prosthetic Fabrication Inc.

O&P world was unintentional. He was working as an orthopedic operating room technician in Huntington, West Virginia, back in 1979, and often worked with two certified orthotist/prosthetists from a local practice. One day he visited their facility and ended up taking a new job fabricating prostheses. A subsequent stint with a company in Orlando, Florida, taught him how to manage work flow in a central fabrication facility, and in 1990, he and his father launched Grace Prosthetic Fabrication. In 1991, Ed’s brother, Tony Culver, joined the company as assistant fabricator, eventually becoming vice president, and their father retired in 2005. Grace’s first location was a garage storage shed equipped with hand tools. “We didn’t even have a real router,” Grace recalls. “We used a sump pump motor with a shaft on it, screwed to a pole in the middle of the garage.” Today, Grace Prosthetic Fabrication owns and occupies a 5,000-square-foot building and is about to add on another 7,500 square feet. The company offers central fabrication services in orthotics and prosthetics for the United States and Puerto Rico, with some orders coming from as far away as Ireland. The company has 12 employees, and Grace says he works to maintain low turnover. “When I get good people, I do what I have to to keep them here. One of my employees has been with us for 17 years,” he says. The company uses Shapermaker and TracerCAD programs to produce prosthetic sockets. Clients

Have you Heard the News That Mobility Saves?

A major new study has proven that prosthetic and orthotic care saves money for payers and improves lives for patients.

The Study A major new study shows that Medicare pays more over the long term in most cases when Medicare patients are not provided with replacement lower limbs. The study was commissioned by the Amputee Coalition and conducted by Dr. Allen Dobson, health economist and former director of the Office of Research at CMS. The study used Medicare data to compare patients with similar conditions who received prosthetics with patients who needed but did not receive prosthetics, over an 18 month period.

The Results

EXHIBIT 4.9 Lower Extremity Prostheses Cumulative Medicare Episode Payment by Cohort (18 Month Episodes from 2008-2010)

Lower Limb Prosthetics

•

The prosthetic patients could experience better quality of life and increased independence compared to patients who did not receive the prosthesis at essentially no additional cost to Medicare or to the patient.

100000

Study Group Average Cumulative Medicare Payments

•

The slope of the cumulative cost curve indicates that had the period of evaluation been longer the break-even would have been reached.

To learn more about the campaign, visit

80000

40000

20000

www.MobilitySaves.org.

Comparison Group

60000

9 10 11 12 13 14 15 16 17 18

Months from Index (Receipt of O&P)

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MEMBER SPOTLIGHT

Presque Isle Medical Technologies

By DEBORAH CONN

Coordinated Care Established facility leverages multiple strategies, including mobile O&P

N 1974, MORTON HEIFETZ, one

MAY 2015 | O&P ALMANAC

Jonathan Heifetz, CPO, collaborates with Joao Tavares, MD, in a team approach to treat a young patient.

FACILITY: Presque Isle Medical Technologies OWNER: Jonathan Heifetz, CPO LOCATIONS: Erie, Pennsylvania; South Euclid, Ohio; and mobile satellites in the Baltimore metro area and Chicago HISTORY: 41 years

Pierre Mason, CPO, travels by mobile van to treat patients at home.

in Chicago and the Baltimore metropolitan area, extending into parts of Maryland, Virginia, and Washington, D.C. The mobile vans are equipped with all tools needed for fittings and adjustments and staffed with certified practitioners who serve patients at home, rehab facilities, nursing homes, and hospitals. The idea for the vans arose when Heifetz and his son realized the value of coordinating care among therapists, doctors, and O&P clinicians. “The key is collaboration. Patients can get answers to all of their questions when all of the team members are present,” says Shlomo Heifetz. Presque Isle had used this model with great success at the Shriners hospital and found an enthusiastic reception among therapists in the D.C. area and then in Chicago. The company has 18 employees, including eight certified practitioners. Roughly 60 percent of its work is in orthotics, although most of that is centered in the Erie office because of its focus on pediatric orthotics with Shriners patients. Most commonly, Jonathan Heifetz treats children

with complex musculoskeletal conditions including cerebral palsy, myelodysplasia, plagiocephaly, torticollis, and scoliosis. “I have a strong expertise in scoliosis,” he says. “I was the first commercially trained orthotist in the SpineCor scoliosis bracing system, and I studied with Min Mehta, MD, whose infantile scoliosis protocol is the gold standard.” Presque Isle Medical Technologies uses its website and social media to market its services, although its longstanding relationship with Shriners accounts for the bulk of its business in Erie. In Chicago and the D.C. area, the mobile van practitioners often hold in-services for therapists that offer continuing education credits. In addition to providing highquality clinical services, Presque Isle prides itself on its attention to the business of O&P. “You need strong management on the business and reimbursement side,” says Shlomo Heifetz. “More and more, you have to stay on top of the minute details of billing claims and how they affect cash flow.” Presque Isle just sold a division that provided complex rehab and customized seating for wheelchairs. Those 10 years in the wheelchair industry, which had to cope with CMS audits long before they hit the O&P field, enabled the facility to refine and solidify its processes and documentation, says Shlomo. “Now we’re one step ahead and we feel very well prepared to tackle any audit challenges that may arise.” Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net.

PHOTOS: Presque Isle Medical Technologies

of the early graduates of the New York University orthotics program, opened his practice in Cleveland. He worked frequently with patients at the Shriners Hospital for Children in Erie, Pennsylvania, about an hour and a half away, and a few years later moved to that city to be closer to the hospital and focus on pediatric orthotics. Heifetz’s son, Jonathan, a graduate of Northwestern’s P&O program and a certified prosthetist-orthotist, took over the family business, Presque Isle Medical Technologies, in 1995, and continues the facility’s close relationship with Shriners. Jonathan’s son Shlomo joined the company in 2012 as director of operations. Last year, Jonathan’s son-in–law, Dov Belsky, established and developed the Chicago mobile services division. Another son, Sam Heifetz, is a certified prosthetist working on the East Coast. Presque Isle’s main facility in Erie occupies about 7,000 square feet and includes three patient rooms and a fabrication lab. “When we moved into this building 10 years ago, it was an open box that we could design for ourselves,” says Jonathan Heifetz, CPO. The lab features a main assembly area in the center, surrounded by pods. “We have a plaster modification room, oven room, sewing room, and machine room. It’s a great use of space and allows us to designate clean rooms and quiet areas.” In addition to its Erie headquarters, Presque Isle Medical Technologies has a smaller facility in South Euclid, Ohio, and two mobile satellite offices

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Techcentric Techcentric An inside look at how one confident and driven tech helps propel the O&P profession forward Why I Do What I Do I had to have my right foot amputated at 10 and I found it so interesting that someone could make something to help me run and walk like the other kids. I told the chief of staff that someday I wanted to come and work with him in the prosthetics department!

ABC Certified or Bust I wanted to show people that I knew what I was doing. People look at where you’ve been, how far you’ve gone and what accomplishments you’ve made. ABC certification shows that you’re truly dedicated to your work and profession.

Tech Tool I Can’t Live Without My hands! And the other skilled and driven techs around me who push me to do my best.

How I Handled the Haters I put all of my attention on relationships with people that wanted to help and work with me. Some people tried to slow me down, make me think that certification didn’t matter and that it was too hard. Glad I proved them wrong!

The Best Advice I Ever Got • Give it to God and he’ll take care of it • Never let anyone tell you that you can’t do something when you know you can (thanks Mom!)

Three Tips I’d Give Someone Scared They Can’t Pass the ABC Exam

What I’d Ask a Tech Who Isn’t Certified

• Believe in yourself

What are you waiting for? If you’ve got the experience, put your faith in what you know and move up to the next level. If that doesn’t help, CALL ME and let’s talk about what’s holding you back!

I Keep Up with the Profession by

ABC Certification Has Helped My Career

Going to trade shows, serving on various ABC committees, talking to vendors about new products and most importantly, just getting in there, working and learning hands-on!

It’s opened so many doors for me with a lot of different jobs and helped me garner respect from others in the profession.

• Study and ask questions • Block out all of the people telling you it’s too hard. It’s not!

Robert S. Carlile, CPA, CTPO Texas Scottish Rite Hospital for Children

AOPA NEWS

Enter the Mobility Saves Testimonial Contest Become part of an important public relations campaign that proves cost effectiveness for orthotics and prosthetics. Create a video testimony and become eligible to win $500!

Why Participate?

• • • •

Help patients obtain medically necessary devices. Support the O&P profession. Become part of a major public relations campaign. Help spread the word that orthotic and prosthetic devices not only restore lives but are cost effective, too. • Receive a T-shirt. • One grand prize winner ($500), one second-place winner ($250), and one third-place winner ($100) will be awarded. • All entries must be received by 11:59 p.m. EST on Sept. 30, 2015.

It’s as easy as

1•2•3!

The New Player in Town: Understand How the RAC Contract Works Mastering Medicare Webinar, May 13

Join AOPA on May 13 for an AOPAversity Mastering Medicare webinar that will cover the details of the new Medicare recovery audit contractor (RAC). An AOPA expert will address the following issues: • O&P additional documentation request limits for RAC audits • Proper response times for audits • Changes to expect with the new contractor • Timing of the new contract • Review of the RAC program. 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 online at bit.ly/aopawebinars. Contact Devon Bernard at dbernard@AOPAnet.org or 571/431-0854 with content questions. Contact Betty Leppin at bleppin@ AOPAnet.org or 571/431-0876 with registration questions.

O CE T

WIN0

H AC

$50

1. Create your video testimony by using your smartphone or video camera. 2. Complete the online entry form at bit.ly/MobilitySavesContest 3. Upload your video testimony or email video from your smart phone.

Questions?

Contact AOPA at 571/431-0876 or ymazur@AOPAnet.org.

MAY 2015 | O&P ALMANAC

RAC

AOPA NEWS

30%F

E SAV

The AOPA Coding Experts Are Coming to Philadelphia July 13-14 The world of coding and billing has changed dramatically in the past few years. The AOPA experts are here for you! The Coding & Billing Seminar will teach you the most up-to-date information to advance the coding knowledge of both O&P practitioners and O&P billing staff. The seminar will feature hands-on breakout sessions, where you will practice coding complex devices, including repairs and adjustments. Breakouts are tailored specifically for practitioners and billing staff.

Top 10 Reasons To Go to Philadelpha

1. Get your claims paid. 2. Increase your company’s bottom line. 3. Stay up to date on billing Medicare. 4. Code complex devices. 5. Earn 14 CE credits. 6. Learn about audit updates. 7. Overturn denials. 8. Submit your specific questions ahead of time. 9. Advance your career. 10. Benefit from more than 70 years of combined experience from AOPA coding and billing experts.

EARN CREDITS

14 CE

PER SEMINAR

AOPA Helps You Save As an AOPA member, you are eligible to save up to 30 percent off UPS Next Day Air®, UPS 2nd-Day Air®, and UPS 3-Day Select®. Take advantage of special savings on UPS shipping offered to you as an AOPA member. Through our extensive network, UPS offers you access to solutions that help you meet your special shipping and handling needs. AOPA members can save: • Up to 30 percent off UPS Next Day Air® and Next Day Air Saver® • Up to 23 percent off UPS 2nd-Day Air® and 2nd-Day Air A.M.® • Up to 18 percent of UPS 3-Day Select® • Up to 19 percent on UPS Worldwide Express®/ Saver®/Expedited® Import and 3.5 percent on UPS Standard® Export Import to and from Canada. Your actual discount is calculated on a sliding scale, determined by your total weekly shipping charges. Sign up at www.savewithUPS.com/aopa and start saving on select UPS shipping options. Sign up for a new UPS account or use your existing account. Who doesn’t want to save money?

Don’t miss the opportunity to experience two jam-packed days of valuable O&P coding and billing information. In this audit-heavy climate, can you afford not to attend? Register at bit.ly/2015billing.

O&P ALMANAC | MAY 2015

AOPA NEWS

Annual Operating Performance and Compensation Survey:

Submit Your Survey By June 19

Better Business Performance Starts Here AOPA offers its members the opportunity to participate in an operating Personalized Company performance and compensation survey Performance Report each year. Data from these surveys with Survey Submission provides benchmarks that enable the comparison of your O&P business with those of similar size and location. This information can assist you in identifying strengths and weaknesses and formulating strategies for meeting business goals. Participation is free, and there are some incentives to thank you for investing 60 minutes of your time to complete the survey. Surveys were mailed to members May 1. Participants can complete the hard copy, enter the data online at www.aopa-survey.com, or send data to Industry Insights to have it entered for you. All data is confidential. The deadline for submission is June 19. Participants in the survey receive a free personalized company performance report, comparing their business with others of similar size and location. (This would cost hundreds of dollars from a private consultant.) The published 2015 Operating Performance Report and 2015 Compensation Report are also available free to participants—a $370 value. As an added incentive for participating this year, AOPA is offering the online Mastering Medicare Webcast series free of charge, a $693 value, with 13.5 CE credits available. For more information about the survey, contact Betty Leppin, bleppin@aopanet.org, or 571/431-0876.

n FREE

Stay in the Know— Subscribe to AOPA’s Take! AOPA has designed AOPA’s Take, a new blog to keep you informed with important issues and real-time news that arise within the O&P world. This is a more immediate avenue to find the latest updates. AOPA’s Take is available at no charge to all members of the O&P community, and subscribing is simple. Go to www.aopastake.org and click on the subscribe button. Fill out a few fields, and you’re in! Welcome to AOPA’s Take…..Where you go when you need to know! 44

MAY 2015 | O&P ALMANAC

AOPA’s monthly webinar series is the regulatory and business education that you can count on. No one in the O&P profession knows the ins and outs of Medicare, coding, billing, or Veterans Administration contracting like AOPA. Sign up for all 2015 webinars for only $990 for members, which includes two free webinars. If you missed one, we will send you the recording. The monthly webinars are a great way to bring your staff together for lunchtime learning by AOPA experts. Don’t miss any of the important topics in the webinars planned for the rest of the year: May 13

The New Player in Town: Understand the Recovery Audit Contractor Contract

June 10

Building a Medicare-Approved Compliance Plan

July 8

Who’s on First? Medicare as a Secondary Payor

August 12

Off the Shelf Versus Custom Fit: The True Story

September 9

Prior Authorization, How Does It Work?

October 14

Understanding the LSO/TLSO Policy

November 11

Make a Good Impression: Marketing Yourself to Referrals

December 9

Bringing in the New Year: New Codes and Changes for 2016

AOPA NEWS

PROSTHETICS 2020:

An Invitation to AOPA Members

The O&P profession has endured a veritable sea of change in the past five years, impacting which prostheses and orthoses are available to our patients, as well as how and at what rate our services are paid for by payors. What do the next five years hold in store? What will prosthetics be like five years from now, and what can be done to permit us to help participate and shape that future? It is clear that evidence, outcomes, and research are keystones. All three were front and center at the January AOPA Futures Leadership Conference. A new program, initiated under the title “Prosthetics 2020,” is a collaborative effort to operate as an adjunct to AOPA’s ongoing Survival Imperatives. Prosthetics 2020 is a partnership open to interested companies that want to take a strong, proactive role in shaping the drivers of prosthetic patient care five years down the road. If you share a commitment to protect, fortify, and enhance the recognized, scientifically substantiated value of prosthetic care in the minds of payors, patients, and the general public, consider making an investment to be part of Prosthetics 2020. AOPA will be managing this effort with the assistance of a small expert steering committee to be appointed by AOPA’s president. We are inviting interested AOPA member companies to join in the effort. The program will include establishing an AOPA Medical Advisory Board to help identify the essential endpoints of measuring value in prosthetic care, and in conveying our scientific messages to payors, both in government and in the private commercial insurance community. AOPA envisions that new prospective clinical research studies will need to be developed and funded, to be conducted by the best and the brightest in the prosthetic research world. New rock-solid science may well portend new payment models and better reimbursement. Companies considering participation should recognize that the mission of Prosthetics 2020 goes well beyond AOPA’s annual dues. Each participating company will be required to commit to an initial financial commitment of $35,000, and it would be anticipated that participating companies would need to provide in the range of $35,000 per annum for the next three years largely to sustain the Medical Advisory Board. In the event that the project results in also funding one or more new prospective research studies in prosthetics, additional financial outlays would be needed. Any AOPA member company, and especially those companies with strong engagement in prosthetics, can join in Prosthetics 2020 provided they are willing to contribute their fair share of the costs. This will entitle participants to receive regular detailed reports and invitations to provide advisory input on the progress of the effort. While it is

likely that representatives from a few of the participating companies may be among the members of the steering committee that AOPA’s president appoints to guide the project, that group needs to be organized as a small, flexible, hard-working group. A small steering committee will be formed and will include a physician, researcher, representatives from one or two of the participating companies, and an AOPA leadership representative. All supporting companies will have input in an advisory role. The steering committee will meet, advance research proposals, coordinate with the Medical Advisory Board and make other recommendations/decisions, subject to the overall AOPA governance framework via the AOPA Board of Directors. General reports on the group’s progress will be shared in the form of updates to all AOPA members. The new framework is being undertaken first in the prosthetics profession. Based on the success of the prosthetics initiative, AOPA will consider the prospects for a subsequent parallel effort in the orthotics profession. The success of Prosthetics 2020 will depend on consistently gathering a cohesive working group and substantial resources on a relatively long-term basis, with the doors open to both large and small patient-care facilities and manufacturers. In principle, key premises will include the following: 1. Maintaining equal contributions from each participant 2. Recognizing that accomplishing the purpose of the Prosthetics 2020 initiative will require substantial financial support 3. Abiding by a participation agreement that addresses the long-term nature of the endeavor, termination, etc. For example, funding the Medical Advisory Board alone will likely require more than $100,000 per year. The likelihood is that there will be one or more prospective research studies that evolve, with costs likely to run into the mid six figures for each study. While we need to balance all of these factors, we also need to retain flexibility. One way we can do that is to suggest that as to patient-care facilities and companies that are not engaged at all in the manufacture or prosthetic knees or feet (all manufacturer participants who have any products in either or both of these product lines need to have the same financial stake), we would be open to “pooled” participation—for example, up to three companies may want to join together over multiple years to meet the annual participation fee. AOPA will share details as the committees form and the Prosthetics 2020 initiative advances.

O&P ALMANAC | MAY 2015

AOPA O&P PAC

HE O&P PAC WOULD like to acknowledge and thank the following AOPA members for their recent contributions to and support of the O&P PAC*:

• James Fenton, CPO • Rick Stapleton, CPO • Thomas Watson, CP, LP The O&P PAC advocates for legislative or political interests at the federal level that have an impact on the orthotic and prosthetic community. To achieve this goal, committee members work closely with members of the House and Senate to educate them about the issues, and help elect those individuals who support the orthotic and prosthetic community. To participate in the O&P PAC, federal law mandates that you must first sign an authorization form. To obtain an authorization form contact Devon Bernard at dbernard@ AOPAnet.org. The O&P PAC also would like to acknowledge and thank the following AOPA members for their recent support of O&P PAC-sponsored events: • Rudy Becker Jr. • Tom Becker • James Campbell, PhD, CO • Maynard Carkhuff • Rodney Cheney, CPO, FAAOP • Ron Cheney • Jeff Collins, CPA • Charles Dankmeyer Jr., CPO • Joseph Delorenzo, CP

MAY 2015 | O&P ALMANAC

• • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Thomas Fise, JD Rick Fleetwood, MPA Elizabeth Ginzel, CPO Lisa Guichet Hanger PAC Thomas Kirk, PhD Eileen Levis Sam Liang Pam Lupo, CO Sara McDonald Schuyler Nelson Michael Oros, CPO, FAAOP Michael Park Andrew Pedtke Rick Riley, CEO Brad Ruhl Scott Schneider Donald Shurr, CP, PT Christopher Snell Clint Snell, CPO Peter Thomas VGM PAC Thomas Watson, CP, LP Jim Weber, MBA Ashlie White Eddie White, CPO James Young Jr., CP, FAAOP Pam Young Travis Young, CPA

*Due to publishing deadlines this list was created on April 1, 2015, and includes only donations/contributions made or received between March 1, 2015, and April 1, 2015. Any donations/contributions made or received on or after April 1, 2015, will be published in the next issue of the O&P Almanac.

WELCOME 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 www.AOPAnet.org member of AOPA if, within 30 days of publication, no objections are made regarding the companyâ&#x20AC;&#x2122;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 AOPAâ&#x20AC;&#x2122;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.

Ferraro & Forbes Inc. 8 Golf View Drive Hingham, MA 02043 781/740-1778 Category: Patient-Care Facility Asanki Abeyratne

Hanger Clinic 1660 S. Second Street Gallup, NM 87301-5836 Category: Affiliate Parent Company: Hanger Clinic

Hanger Clinic 15043 Bruce B Downs Blvd. Tampa, FL 33647-1388 Category: Affiliate Parent Company: Hanger Clinic

Hanger Clinic 1614 Louetta Road Spring, TX 77388-4787 Category: Affiliate Parent Company: Hanger Clinic

Hanger Clinic 25420 Highway 1, Ste. D Plaquemine, LA 70764-7513 Category: Affiliate Parent Company: Hanger Clinic

Hanger Clinic 1220 Coit, Ste. 102 Plano, TX 75075-7757 Category: Affiliate Parent Company: Hanger Clinic

Hanger Clinic 1 Mercado Street, Ste. 203 Durango, CO 81301-7309 Category: Affiliate Parent Company: Hanger Clinic

Hanger Clinic 1000 S. Loop West, Ste. 150 Houston, TX 77054-4696 Category: Affiliate Parent Company: Hanger Clinic

Hanger Clinic 9711 Medical Center Drive, Ste. 106 Rockville, MD 20850-3323 Category: Affiliate Parent Company: Hanger Clinic

Hanger Clinic 1210 Gemini Place, Ste. 101 Columbus, OH 43240-6109 614/436-3516 Category: Affiliate Parent Company: Hanger Clinic

Hanger Clinic 1222 Orange Avenue, Ste. B Winter Park, FL 2789-4918 Category: Affiliate Parent Company: Hanger Clinic

Innovative Prosthetic & Orthotic Professionals Inc. 1750 Humboldt Street, Ste. 102 Denver, CO 80218 303/832-1750 Category: Patient-Care Facility Paula Englander, JD

Hanger Clinic 1126 S. Division Avenue Orlando, FL 32805-4701 Category: Affiliate Parent Company: Hanger Clinic Hanger Clinic 3244 Kimball Avenue Manhattan, KS 66503-0000 785/537-8897 Category: Affiliate Parent Company: Hanger Clinic

Tailor Made 3160 Southgate Commerce Blvd., Ste. 38C Orlando, FL 32806 407/245-7770 Category: Supplier Level 1 Ultraflex Systems 237 South Street Pottstown, PA 19464 610/906-1410 Category: Patient-Care Facility Mark DeHarde

Is Your Facility Celebrating a Special Milestone in 2015? O&P Almanac would like to celebrate the important milestones of established AOPA members. To share information about your anniversary or other special occasion to be published in a future issue of O&P Almanac, please email cumbrell@ contentcommunicators.com.

O&P ALMANAC | MAY 2015

MARKETPLACE

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

Allard 3D-LITE LSO Xtra: Customize Your OTS LSO! 3D-LITE™ LSO Xtra with 5-mm low-temp thermoplastic heat moldable posterior panel that extends to each side for added rotation control. The posterior panel can be remolded as needed. Customize at time of delivery with easily documented modification process. Patient can easily slip hands into hand loops sewn onto both anterior panels for simplified donning and doffing. Boost patient compliance with a comfortable back support that delivers the stability your patient needs. Five sizes fit from 23 ½” to 55” waists. PDAC letter available for L0631. For more information, contact Allard USA at 888/678-6548 or visit www.allardusa.com.

Aqualeg With New Soft Shell Technology The Aqualeg soft shell cover has an exact fit and is self-supporting without the need for foam underneath. This allows the cover to be used in and around water. It has flexibility modeled after real limbs and is available in a precise 3D custom fabrication. Every cover is produced to fit perfectly on the socket. The covers are intended to be used everyday and provide a solution for active people who have lifestyles that include getting into water or harsh environments. They offer the perfect solution for prosthetic devices that are traditionally difficult to cover, including those with electronic components or vacuum assistance. For more information, contact Aqualeg Inc. at 855/955AQUA (855/955-2782) or visit www.aqualeg.com.

MAY 2015 | O&P ALMANAC

ePAD: The Electronic Precision Alignment Device The ePAD shows precisely where the point of origin of the ground-reaction force (GRF) vector is located in sagittal and coronal planes. The vertical line produced by the selfleveling laser provides a usable representation of the direction of the GRF vector, leading to valuable weight positioning and posturing information. For more information, contact DAW Industries Inc. at 800/252-2828, email info@daw-usa.com, or visit www.daw-usa.com.

New Sure Stance Knee by DAW This ultralight, true-variable cadence, multiaxis knee is the world’s first 4-bar stance control knee. The positive lock of the stance control activates up to 35 degrees of flexion. The smoothness of the variable cadence, together with the reliability of toe clearance at swing phase, makes this knee the choice prescription for K-3 patients. For more information, contact DAW Industries Inc. at 800/252-2828, email info@daw-usa.com, or visit www.daw-usa.com.

Dynamic Chopart Gait Stabilizer This unique ankle-foot orthosis (AFO) has been designed for Chopart amputees who wish to remain active. Often a traditional full-length AFO for this patient will be stiff, feeling unnatural. Using a hinged ankle and flexible foot plate with a segmented dynamic filler allows flexion before providing a “stop” that protects the residuum and prevents shoe vamp collapse. The PTB design and the anterior shell redistribute groundreaction forces up the lower extremity. For more information, contact at 800/301-8275 or visit www.hersco.com.

MARKETPLACE 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 AFO 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, contact at 800/301-8275 or visit www.hersco.com.

Introducing the Stronger, Smarter, Submersible Plié® 3 MPC Knee

Stronger construction makes the new Plié 3 Microprocessor Controlled (MPC) knee both submersible and more rugged than ever. Yet it’s still the fastest MPC knee, responding 10 to 20 times more rapidly than other MPC knees. With the most responsive stumble and fall protection, users can instinctively move at their own pace in any direction...even if it’s taking small short steps or pivoting in confined spaces. And with a more streamlined, intuitive set-up, the Plié 3 MPC knee makes it even easier for prosthetists to help patients expand their freedom. To learn more about the Plié 3 MPC knee, contact Freedom Innovations at 888/818-6777 or visit www.freedom-innovations.com.

Freedom Foot Products Just Got Better

Now, with the broadest range of sandal-toe options available anywhere, you can focus first on performance and rest assured that your patient’s desire to wear sandals can be easily satisfied. Achieve improved clinical outcomes by delivering a product designed to meet your functional objectives. Whether it’s shock absorption, hydraulic ankle motion, heel height adjustability, or multiaxial ground compliance, the new sandal-toe product line delivers form and function—unrestricted. Choose from 13 high-performance designs: • Highlander® • Kinterra® • Pacifica® & Pacifica® LP • Renegade® & • Runway® & Runway® HX Renegade® LP • Thrive® • Agilix™ • WalkTek® • DynAdapt™ • Sandal-Toe Foot Shell • Sierra® Our second-generation Sandal-Toe Foot Shell is available in sizes 22-28 cm and in three different skin tones (light, medium, and dark). For additional information, contact customer service at 888/818-6777 or email us at info@freedom-innovations.com.

Össur Iceross® Seal-In® X. Make Your Move! With a moveable seal ring to ensure optimal seal positioning, Seal-In X offers both maximum comfort for users with uniquely shaped or sensitive limbs and easier donning and doffing for users with compromised hand dexterity. Seal-In X also features seamless Anatomy Conforming Fabric, a durable yet flexible weave that comfortably controls soft tissue and elongates over the knee without bunching in the popliteal region. Plus, Seal-In X is Unity® compatible, so your patients can experience all the benefits of sleeveless vacuum, as well. For more information, visit www.ossur.com or contact your Össur® representative today.

O&P ALMANAC | MAY 2015

MARKETPLACE

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

EMS Socket Exclusively From Ottobock The EMS flexible inner socket provides up to 100 percent more surface area for better force distribution and 400 percent more coefficient of friction for better linkage to socket. All of that translates into an advanced socket with superb connection for your patients who use Harmony vacuum suspension. In addition to the enhanced connection, EMS includes lower definitive socket trim lines for greater range of motion and reduced wear on sleeves. The EMS is available exclusively from Ottobock by calling your local sales rep at 800/328-4058 or logging onto www.ottobockus.com.

Ottobock’s 6Y90 Locking and 6Y92 Cushion TPE Liners Ottobock’s 6Y90 locking and 6Y92 cushion TPE liners include medical-grade mineral oil to help skin conditioning, and a distal control matrix in the 6Y90 helps to reduce pistoning and elongation. The 6Y90 and 6Y92 are thermoformable over a plaster mold for individual shaping and include a seamless textile cover that resists fraying when cut. These liners are available in 200-, 250-, 280-, 320-, and 360-mm sizes. For more information, contact your sales representative at 800/328-4058 and ask about Ottobock’s 6Y90/6Y92 TPE liners.

New AxonHook From Ottobock

For maximum versatility, precision, and power, look for this latest addition to the AxonBus Family—the AxonHook. The AxonHook is the perfect complement to the Michelangelo Hand. It includes titanium with polyurethane coated fingers so the AxonHook can provide superb precision and power, making it the perfect companion to the Michelangelo Hand. For more information, contact your sales representative at 800/328-4058 for details. 50

MAY 2015 | O&P ALMANAC

Spinal Technology Spinal Technology Inc. is a leading central fabricator of spinal orthotics, upper- and lower-limb orthotics, and prosthetics. Our ABC-certified staff orthotists/prosthetists collaborate with highly skilled, experienced technicians to provide the highest quality products and fastest delivery time, including weekends and holidays, as well as unparalleled customer support in the industry. Spinal Technology is the exclusive manufacturer of the Providence Scoliosis System, a nocturnal bracing system designed to prevent the progression of scoliosis, and the patented FlexFoam™ spinal orthoses. For information, contact 800/253-7868, fax 888/775-0588, email info@spinaltech.com, or visit www.spinaltech.com.

2015 AOPA Coding Products

• • • • •

Get your facility up to speed, fast, on all of the O&P HCPCS code changes with an array of 2015 AOPA coding products. Ensure each member of your staff has a 2015 Quick Coder, a durable, easyto-store desk reference of all of the O&P HCPCS codes and descriptors. Coding Suite (includes CodingPro single user, Illustrated Guide, and Quick Coder): $350 AOPA members, $895 nonmembers. CodingPro CD-ROM (single-user version): $185 AOPA members, $425 nonmembers. CodingPro CD-ROM (network version): $435 AOPA members, $695 nonmembers. Illustrated Guide: $185 AOPA members, $425 nonmembers. Quick Coder: $30 AOPA members, $80 nonmembers.

Order at www.AOPAnet.org or by calling AOPA at 571/431-0876.

Products & Services

For Orthotic, Prosthetic & Pedorthic Professionals

2014 OPERATING PERFORMANCE REPORT AOPA Helps Run

s s e n i s u B r u Yo 2014 OPERATING PERFORMANCE REPORT

AOPA Operating Performance Report

2014

(Reporting on 2013 Results)

Are you curious about how your business compares to others? This updated survey will help you see the big picture. The Operating Performance Report provides a comprehensive financial profile of the O&P industry including balance sheet, income statement and payer information organized by total revenue size, community size and profitability. The data was submitted by more than 98 patient care companies representing 1,011 full time facilities and 62 part-time facilities. The report provides financial performance results as well as general industry statistics. Except where noted, all information pertains to fiscal year 2012 operations. Electronic Version AOPA Member: $85.00 Non-Members: $185.00

HOW TO ORDER BY FAX: 571/431-0899

PUBLICATIONS. EDUCATION. SERVICES. Everything you need to manage a successful patient care facility.

ONLINE: www.AOPAnet.org BY MAIL: AOPA Bookstore, 330 John Carlyle Street, Suite 200, Alexandria, VA 22314 MORE INFORMATION: For AOPA products and educational opportunities, contact 571/431-0876 or e-mail info@AOPAnet.org.

AOPA NEWS

CAREERS

Opportunities for O&P Professionals

Southeast

Job location key:

Certified Prosthetist-Orthotist

Johnson City, Tennessee Well-established multioffice ABC-certified O&P company is looking for certified individual with excellent orthotic and prosthetic skills to provide comprehensive treatment of patients. Excel offers competitive salary and bonus opportunity with full benefits package. Salary to be determined on experience. Send resume to:

- Northeast - Mid-Atlantic - Southeast - North Central - Inter-Mountain - Pacific

Hire employees and promote services by placing your classified ad in the O&P Almanac. When placing a blind ad, the advertiser may request that responses be sent to an ad number, to be assigned by AOPA. Responses to O&P box numbers are forwarded free of charge. Include your company logo with your listing free of charge. Deadline: Advertisements and payments need to be received one month prior to publication date in order to be printed in the magazine. Ads can be posted and updated any time online on the O&P Job Board at jobs.AOPAnet.org. No orders or cancellations are taken by phone. Submit ads by email to 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. O&P Almanac Careers Rates Color Ad Special 1/4 Page ad 1/2 Page ad

Member $482 $634

Nonmember $678 $830

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

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

Member Nonmember $80 $140

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

Discover new ways to connect with O&P professionals. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net. Visit bit.ly/aopamedia for advertising options.

MAY 2015 | O&P ALMANAC

Email: sethwalters@excel-prosthetics.com

Pacific Here We Grow Again… Openings: CPO, CP, and CO

Orange County, Riverside County, San Bernardino County, California A reputable, well-established, multioffice, Southern California O&P company is looking for energetic and motivated individuals who possess strong clinical skills and experience to provide comprehensive patient assessments to determine patient needs, formulate and provide treatments, perform necessary protocols to ultimately deliver the best orthotic/prosthetic services, and provide follow-up patient care. Candidates must have excellent communication, patient-care, and interpersonal interaction skills, and always abide by the Canons of Ethical Conduct instilled by ABC. We offer competitive salaries and benefits. Salary is commensurate with experience. Local candidate preferred. Send resumé to:

Attention: Human Resources Inland Artificial Limb & Brace, Inc. Fax: 951/734-1538 SUBSCRIBE

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

CAREERS

ORTHOTICS & PROSTHETICS

Career Opportunities Career Opportunities Available

Our Mission

Available TO SEEK OUT dedicated Orthotic and Prosthetic practitioners

We are currently seeking Orthotists/Prosthetists for our clinics in: PA, NJ, MD, NC, SC,TO GA, FL and TX. HIRE AND TRAIN individuals to fabricate orthotic and prosthetic devices that meet It is the mission of all members of Level Four to ensure each patient is able Pediatric Experience a that plus. specialized needs

We are currently seeking Orthotists/Prosthetists for our clinics in: ORTHOTICSTO& PROSTHETICS MAINTAIN continuing education standards PA, NJ, MD, NC, SC, GA, FL and TX. Pediatric Experience a plus.

Our Mission

to reach their maximum functional potential in life — THE FOURTH LEVEL — whereItpowered by the human spirit,of science technology working together, is the mission all and members of Level we serve to maximize the human experience.

Four to ensure that TO EDUCATE a group of insurance professionals to maximize patient benefits each patient is able to reach their maximum functional poTO BUILD an O&P organization that can remain tential in life — THE FOURTH LEVEL — where powered by the independent in a rapidly consolidating field Please note several states require licensure in addition to certification. human spirit, science and technology working together, we Please submit resume to opportunities@level4oandp.com We are currently seeking Orthotists/Prosthetists for our clinics in: serve to maximize the human experience.

Career Opportunities Available

PA, NJ, MD, NC,states SC,require GA, FL and TX. Pediatric Experience Please note several licensure in addition to certification.

TO SEEK OUT dedicated Orthotic and Prosthetic practitioners TO MAINTAIN continuing education standards

a plus.

Our Mission It is the mission of all members of Level Four to ensure that each patient is able TO SEEK OUT dedicated Orthotic and Prosthetic practitioners to reach their maximum functional potential in life — THE FOURTH LEVEL — TO MAINTAIN continuing education standards where powered by the human spirit, science and technology working together, TO HIRE AND TRAIN individuals to fabricate orthotic and prosthetic devices that meet specialized needs we serve to maximize the human experience. TO EDUCATE a group of insurance professionals to maximize patient benefits TO BUILD an O&P organization that can remain independent in a rapidly Please note several consolidating field states require licensure in addition to certification.

TO HIRE AND TRAIN individuals to fabricate orthotic and prosthetic devices that meet specialized needs TO EDUCATE a group of insurance professionals to maximize patient benefits TO BUILD an O&P organization that can remain independent in a rapidly consolidating field

Please submit resume to Please opportunities@level4oandp.com submit resume to opportunities@level4oandp.com

The Source for Orthotic & Prosthetic Coding

Morning, noon, or night— LCodeSearch.com allows you access to expert coding advice—24 hours a day, 7 days a week.

HE O&P CODING EXPERTISE the profession has come to rely on is available online 24/7! LCodeSearch.com allows users to search for information that matches L Codes with products in the orthotic and prosthetic industry. Users rely on it to search for L Codes and manufacturers, and to select appropriate codes for specific products. This exclusive service is available only for AOPA members.

Log on to LCodeSearch.com and start today. Need to renew your membership? Contact Betty Leppin at 571/431-0876 or bleppin@AOPAnet.org.

NEW

Manufacturers: for 2015! AOPA is now offering Enhanced Listings on LCodeSearch.com. Don’t miss out on this great opportunity for buyers to see your product information! Contact Betty Leppin for more information at 571/431-0876.

www.AOPAnet.org

O&P ALMANAC | MAY 2015

CALENDAR June 11-12

2015

MOPA: Michigan Continuing Education Meeting. DoubleTree by Hilton Bay City-Riverfront. Now offering pedorthic continuing education credits. Contact 517/784-1142 or visit www.mopa.info.

May 11-16

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 250 locations nationwide. For more information call 703/836-7114, or send email to certification@abcop.org, or visit www.abcop.org/certification.

June 17-19

New York State Chapter Annual Meeting. Pediatrics and more. Albany Marriott, Albany, NY. For information, visit www.NYSAAOP.org.

June 19-20

PrimeFare East Regional Scientific Symposium 2015. National Convention Center, Nashville, TN. Sponsored by ReliaCare Alliance IPA. For more information, visit www.primecareop.com or contact Jane Edwards at 888/388-5243 or jedwards@reliacare.com.

May 13

The New Player in Town: Understand How the RAC Contract Works. Register online at bit.ly/aopawebinars. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org. Webinar Conference

July 8

Who’s on First? Medicare as a Secondary Payer. Register online at bit.ly/aopawebinars. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org. Webinar Conference

June 1

ABC: Practitioner Residency Completion Deadline for July Written and Written Simulation Exams. All practitioner candidates have an additional 30 days after the application deadline to complete their residency. For more information call 703/836-7114, or send email to certification@abcop.org, or visit www.abcop.org/certification.

July 13-14

AOPA: Mastering Medicare Essential Coding & Billing Techniques Seminar. Philadelphia. Register online at bit.ly/2015billing. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org.

June 10

Stay Out of Trouble: Building a Webinar Conference Medicare-Approved Compliance Plan. Register online at bit.ly/aopawebinars. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org.

August 12

Off the Shelf vs. Custom Fit: The True Story. Register online at bit.ly/aopawebinars. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org. Webinar Conference

Year-Round Testing

Online Training

BOC Examinations. BOC has year-round testing for all of its exams and no application deadlines. Candidates can apply and test when ready and receive their results instantly for the multiple-choice and clinical-simulation exams. Apply now at my.bocusa.org. For more information, visit www.bocusa.org or email cert@bocusa.org.

Cascade Dafo Inc. Cascade Dafo Institute. Now offering a series of six free ABC-approved online courses, designed for pediatric practitioners. Visit www.cascadedafo.com or call 800/848-7332.

www.bocusa.org

Calendar Rates Let us share your upcoming event! Telephone and fax numbers, email addresses, and websites are counted as single words. Refer to www. AOPAnet.org for content deadlines.

MAY 2015 | O&P ALMANAC

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

CREDITS

BONUS! Listings will be placed free of charge on the “Attend O&P Events” section of www.AOPAnet.org.

Words/Rate: Member Nonmember Color Ad Special: Member Nonmember 25 or less

$40

$50

1/4 page Ad

$482

$678

26-50

$50

$60

1/2 page Ad

$634

$830

51+

$2.25/word $5.00/word

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.

CALENDAR November 4-6

September 9

Prior Authorization, How Does Webinar Conference It Work? Register online at bit. ly/aopawebinars. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org.

NJAAOP. The New Jersey Chapter of AAOP presents the 21st Annual Continuing Education Seminar. Harrah’s Atlantic City, NJ. For more information contact Lisa Lindenberg at 973/6092263, or email director@njaaop.org, or visit www.njaaop.com.

November 9-10

October 1-3

2015 NC-SC Annual Meeting. The Ballantyne, Charlotte, NC. More information online at www. ncaaop.com/joinrenew-membership. For exhibitors and sponsorship opportunities, contact Jennifer Ingraham jingraham@spsco.com or 800/767-7776, x1173, or contact Skyland Prosthetics at 828/684-1644.

October 7-10

98th AOPA National Assembly. The Henry B. Gonzalez Convention Center, San Antonio. More information at bit.ly/2015assembly. For exhibitors and sponsorship opportunities, contact Kelly O’Neill, 571/4310852, or koneill@AOPAnet.org. General inquiries, contact Betty Leppin at 571/431-0876 or bleppin@AOPAnet.org.

October 14

Understanding the LSO/TLSO Policy. Register online at bit.ly/ aopawebinars. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org. Webinar Conference

AOPA: Mastering Medicare Essential Coding & Billing Techniques Seminar. The Flamingo, Las Vegas. Register online at bit.ly/2015billing. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org.

November 11

How To Make a Good Impression: Marketing Yourself to Your Referrals. Register online at bit.ly/aopawebinars. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org. Webinar Conference

December 9

Bringing in the New Year: New Codes and Changes for 2016. Register online at bit.ly/aopawebinars. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org. Webinar Conference

ADVERTISERS INDEX

Company

Page Phone

Website

4tellSoftware Inc.

888/261-7113

www.4tellsoftware.com

ABCOP - American Board for Certification in Orthotics, Prosthetics, & Pedorthics Inc.

703/836-7114

www.abcop.org

Ability Dynamics

855/450-7300

www.abilitydynamics.com

Allard USA

888/678-6548

www.allardusa.com

Aqualeg Inc.

855/955-2785

www.aqualeg.com

Amputee Coalition

888/267-5669

www.amputee-coalition.org

Cailor Fleming Insurance

800/796-8495

www.cailorfleming.com

Cascade Dafo

800/848-7332

www.cascadedafo.com

Custom Composite

866/273-2230

www.cc-mfg.com

DAW Industries

800/252-2828

www.daw-usa.com

Freedom Innovations

888/818-6777

www.freedom-innovations.com

Hersco

800/301-8275 www.hersco.com

Össur Americas Inc.

800/233-6263

www.ossur.com

Ottobock

800/328-4058 www.professionals.ottobockus.com

Spinal Technology Inc.

800/253-7868

www.spinaltech.com O&P ALMANAC | MAY 2015

ASK AOPA

When Medicare Says ‘No’ Providing items that are considered “noncovered” requires a thorough understanding of the Medicare guidelines 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.

Am I required to have an advanced beneficiary notice (ABN) signed and on file for items or services that are considered noncovered by Medicare?

No, you are not required to have a signed ABN on file for items that are considered statutorily noncovered by Medicare. However, you may choose to use the ABN form as a way to notify the patient in writing that the item or service he or she is receiving is noncovered by Medicare and that he or she will be responsible for payment. If you don’t have the patient sign the ABN form, or any other notice of exclusion from Medicare benefits form, you may still charge and collect the money from the patient for any noncovered Medicare item.

If I am providing a noncovered item/service to a Medicare beneficiary and I have them sign the ABN form, which modifier do I use if I am submitting the claim to Medicare?

Remember if an item is considered noncovered by Medicare, you are not required to submit the claim to Medicare and you may collect money directly from the patient. If the patient wishes you to submit the claim, perhaps because that patient has a secondary insurance, and you have the patient sign an ABN, do not use the GA modifier. If the item you are providing is noncovered, you should submit the claim with the GY modifier. The GY modifier is always used to demonstrate that the item or service is “statutorily excluded and doesn’t meet the definition of any Medicare benefit.”

MAY 2015 | O&P ALMANAC

If I know Medicare will deny the item/service I am providing as not medically necessary and the patient refuses to sign the ABN, may I refuse to provide the item or service to the beneficiary?

Yes. The ABN is designed to provide you with some financial liability protection and shift the liability to the patient. If the patient refuses to sign the ABN you provided, with a detailed description of why you believe the item/service you are providing may be denied, then you are under no obligation to provide that particular item or service to the patient.

If we know the item or service we are about to provide will be denied as not medically necessary and the patient doesn’t sign an ABN, and we still wish to provide the item or service, is there a special modifier we should use, or do we simply submit the claim as we normally would?

If you know without a doubt the item will be denied as not medically necessary and you choose to accept the financial liability if the claim is denied, then you should submit your claim with the GZ modifier. When a claim is submitted with the GZ modifier, Medicare will automatically deny the claim and you may then begin the appeals process. However, if you are unsuccessful in your appeals attempts, you may not collect any money from the patient.

Amputee Coalition 2015 National Conference

amputee-coalition.org/2015-national-conference

Tucson

Arizona

JW Marriott Starr Pass Resort & Spa Thursday, July 23 â&#x20AC;&#x201C; Saturday, July 25, 2015 Contact us at 888/267-5669 or visit amputee-coalition.org for more info.

Michelangelo is the natural choice Natural design and incredible freedom of movement Give your patients the intuitive, responsive functionality of Michelangelo that brings them closer to a natural hand than any other myoelectric. The Michelangelo difference is more than cosmetic. It offers seven different hand positions and a powerful grip function. Along with its flexible wrist, unique fingertips, and electronically movable thumb, Michelangelo can open up a whole new world of possibilities for your upper limb patients. Ask your local sales rep to trial a Michelangelo today and see how it has become the natural choice.