October 2015 O&P Almanac by AOPA

The Magazine for the Orthotics & Prosthetics Profession

O CTO B E R 2015

UNITED We Stand

STORIES OF SOLIDARITY AND STRENGTH FROM O&P PROFESSIONALS AND AMPUTEES P.30

Why Medicare Could Revoke Your Billing Privileges P.20

Inside the Center for the Intrepid P.40

Disease Trends That Could Affect Your Business P.48

Best Practices for Gift Giving P.52

This Just In: Allied Health-Care Professionals Oppose Draft LCD and Policy Article P.26 E! QU IZ M EARN

BUSINESS CE

CREDITS P.20 & 52

YOUR CONNECTION TO

EVERYTHING O&P

THE ONLY THING BETWEEN AMPUTEES AND A HIGHER QUALITY OF LIFE IS MEDICARE’S GLASS CEILING. MICROPROCESSOR KNEE

DARPA

BIONIC PROPULSION ANKLE

POWER KNEE

As seen in The Washington Post and The Hill

MYOELECTRIC

HIGH ENERGY FOOT

Medicare’s glass ceiling moves today’s prosthetic devices out of reach for most amputees. Decades of technological advancements mean that new levels of mobility, health and

Amputees Who Receive Better Prostheses Save Medicare Money*

Though new, higher quality custom prostheses are widely available, Medicare

independence are possible for amputees. The only problem? Medicare. The federal

K3 Prostheses (Higher Quality) $79,967

restrictions are a glass ceiling

government makes it highly unlikely that a

that keeps them out of reach

patient will qualify for these devices, and

of most amputees. Even

new regulations will make the situation

K2 Prostheses (Lesser Quality) $81,513

though it’s been shown these devices provide a better

worse, not better. FIRST 12 MONTHS, ALL HEALTH COSTS.

quality of life.

If Medicare is trying to save money, denying

10.3%

amputees prosthetic devices isn’t the

Who has fewer incidents that require

way to do it. A new study shows patients

expensive care? In most cases, it is the

who receive timely prosthetic and orthotic

amputees who have been given the

devices can actually save Medicare money

prosthetics that kept them active and

over patients who are not treated — more

healthy. And now Medicare and its

than $231 million was saved for Medicare in

contractors are planning to further restrict

2014 alone.

who can get these better prosthetic limbs.

fewer skilled nursing claims for people with high-quality prostheses

It’s an outrage that Medicare would deny amputees the life-changing mobility that comes with prosthetics. To learn more about the Medicare study

Who Had Fewer Medical Incidents?

Received Higher Quality Prosthetics

Received Lower Quality Prosthetics

and what you can do to stop these policies, visit mobilitysaves.org.

Fewer E.R. Admissions? Fewer Skilled Nursing Needs? Fewer Doctor Visits? Fewer Hospice Admissions?

* Dobson | DaVanzo analysis of custom cohort Standard Analytic Files (2007‐2010) for Medicare beneficiaries who received O&P services from January 1, 2008 through June 30, 2009 (and matched comparisons), according to custom cohort database definition.

R EG American Orthotic & Prosthetic Association

IST

RAT

#AO

ION

The premier meeting for orthotic, prosthetic, and pedorthic professionals

IS N

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AOPAnet.org

contents

OCTOB E R 2015 | VOL. 64, NO. 10

FEATURES

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

COVER STORY

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........................................18

Transitions in the profession

30 | United We Stand In an unprecedented showing of unity, O&P practitioners and amputees joined forces on August 26 to rally for a rescission of the draft Local Coverage Determination and Policy Article governing Medicare coverage of lower-limb prostheses. Participants share their experiences and explain how the draft LCD would impact their lives. By Josephine Rossi

26 | This Just In

Strength in Numbers

Gifting Guidelines

P. 26

Breakdown of the Stark Law and the Anti-Kickback Statute CE Opportunity to earn up to two CE credits CREDITS by taking the online quiz.

Member Spotlight................................. 58 n n

P. 40

40 | Serving the Nation’s Finest Prosthetists and orthotists at the Center for the Intrepid take a comprehensive, high-tech approach to patient care, working alongside surgeons, therapists, and technicians to create treatment plans for military amputees and those with severe extremity injuries.

O&P professionals who follow disease trends, such as changes in the treatment of diabetes and cerebral palsy, will be best positioned to treat the patients most likely to visit their facilities in the coming years.

Turbomed Orthotics UT Medicine O&P Clinic at the University of Texas Health Science Center

AOPA News................................................ 62

AOPA meetings, announcements, member benefits, and more

Welcome New Members ..................66

AOPA PAC...................................................68

Marketplace..............................................70

By Catherine Johnson

Dissecting Disease Trends

Suspended Privileges

Strategies for preventing revocation of Medicare billing privileges CE Opportunity to earn up to two CE credits CREDITS by taking the online quiz.

Compliance Corner .............................. 52

Support from across the allied health-care spectrum has bolstered AOPA’s position on the proposed changes to the Local Coverage Determination Policy Article. Researchers, legislators, and representatives from several health-care associations also have voiced their concerns over the proposed revisions.

48 | O&P Almanac Leadership Series

Reimbursement Page........................ 20

P. 48

Careers......................................................... 78

Professional opportunities

Calendar..................................................... 80

Upcoming meetings and events

Ad Index.......................................................82 Ask AOPA.................................................. 84 Expert answers to your questions about nurse practitioner signatures

O&P ALMANAC | OCTOBER 2015

PRESIDENT’S VIEW

All Hands on Deck Specialists in delivering superior treatments and outcomes to patients with limb loss and limb impairment.

ANY OF YOU WILL be reading this issue of the O&P Almanac either late at night or early in the morning because AOPA has distributed a copy to every AOPA National Assembly attendee in San Antonio. The AOPA Assembly Planning Committee has again done a remarkable job putting together what I view as the most comprehensive meeting for all of O&P. Going over the program to map out where to spend my time was no easy task. The topics, top-notch presenters, and timely clinical and business information—there are so many choices, and a track here for everyone! As always, the number and quality of exhibitors guarantee each of us the opportunity to meet face to face with manufacturers and discuss the latest devices and techniques available to enhance the quality of life for the patients we serve. But this annual gathering also is a good time to take stock of where we are, where we’ve been, and our prospects for tomorrow. Most of us would look back and say where we’ve been was truly the “good old days.” We cared for patients, took pride in the results, and kept our primary focus on patients. We are still keeping a primary focus on patients, but it’s getting harder. There’s no need to spend more time bashing CMS regulations, Recovery Audit Contractor audits, administrative law judge delays, and the other vexing problems distracting us from patient care—frankly, we don’t have the time to be gnashing our teeth and exclaiming, “Woe is me.” We can’t afford negative energy because it robs us of the positive energy we need to face what’s next. That is one of the big—and I mean really big—changes we made this year. When the proposed Local Coverage Determination (LCD) for Lower-Extremity Prosthetics Policy Article was published, we made a conscious decision not to go to the durable medical equipment Medicare administrative contractors (DME MACs) begging for a few moments of their precious time. No more negatives, no more “We can’t fight them,” no more begging for them to toss us a bone. We decided to think differently: We have value. What we do has value. You, the DME MACs and your ilk, need us! We took the positive tack, held our collective heads high, and challenged them head on. It feels a lot better to stand up and express our value than it does to submit to oppression. We don’t know what the ultimate outcome of all of our activities on this proposed LCD will be, but we do know that we have won the most important battle: We regained our own self-respect. This is the National Assembly issue of the O&P Almanac, and I need to make a sincere ask of you. You’ve seen colleagues drop by the wayside as O&P facilities have closed or been absorbed by other companies. AOPA has seen that impact big time. Prior to 2012, the annual AOPA membership renewal rate was between 94 and 97 percent year after year, as loyal members pledged their support year after year and made possible our aggressive advocacy. AOPA hasn’t seen that renewal rate since 2012. Yet, by all standards, we’ve continued to deliver on advocacy and other fronts. Saving the O&P community and our patients $100 million per year by securing an O&P exemption from the 2.3 percent medical device excise tax is an annual payback that should have kept everyone on board. In this business, membership is voluntary. When money gets tight, people look for places to cut costs—and voluntary trade association membership fees may seem an easy place to cut. But the profession must remain engaged for AOPA to successfully represent it. Out legislative advocacy has brought tens of millions of dollars into the education and research areas of O&P. These things tend to go unnoticed in the day-to-day operation of an O&P practice, but they are the reason you can still take pride in yourself and your profession. We need everyone engaged. We know there are at least 500 O&P companies that are not members of AOPA—so there are at least 500 companies enjoying the benefits of that device tax exemption, legislative advocacy, regulatory advocacy, insurance advocacy, research funding, education funding, and focused business practice education who don’t participate with one red cent. But they sure don’t mind letting AOPA members pick up the tab. Some of them are attending this meeting, paying the nonmember surcharge. Whether you are reading this magazine while in San Antonio or back in your home town, I ask that you be an advocate for AOPA. Check the AOPA website membership role; if you notice a colleague is not listed, give them a call and ask them to join. Our members have worked together to build a proud and valuable profession. We need all of the rest to join AOPA to keep it that way.

Charles H. Dankmeyer Jr., CPO AOPA President 4

OCTOBER 2015 | O&P ALMANAC

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 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

OCTOBER 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!

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NUMBERS

Rallying for Patient Rights O&P stakeholders gathered August 26 to request a rescission of a proposed LCD

Hundreds of O&P practitioners, patients, manufacturers, and other interested parties gathered in Maryland and Washington, D.C., to engage legislators and officials from the U.S. Department of Health and Human Services and share their concerns about the proposed Local Coverage Determination (LCD) for LowerExtremity Prosthetics Policy Article.

PREHEARING ACTIVITY

DME MAC HEARING IN MARYLAND

AMPUTEE PATIENT RALLY IN WASHINGTON

Five

>108,000

Signatures on “We the People” petition opposed the proposed LCD.

150

Registered speakers attended.

Participants took part in the demonstration.

Five

Hours of presentations were given.

Eight AOPA/O&P representatives met with senior HHS officials.

“CMS promised that they will be their DME MAC contractors, and stated that cost savings are not a justification for LCD

Seconds

Length of the television spots purchased by AOPA on several news stations.

DARPA

MICROPROCESSOR KNEE

BIONIC PROPULSION ANKLE

POWER KNEE

MYOELECTRIC

HIGH ENERGY FOOT

400+

No No No No Articles/television stories in print, television, and electronic media appeared immediately following the event. Medicare, please don’t disable us!

OCTOBER 2015 | O&P ALMANAC

supported by evidence from research/medical literature. Overall, it was a very good day for O&P.” —Tom Fise, JD, AOPA Executive Director, commenting on August 26 meeting with HHS officials

MEDIA COVERAGE

Pages of comments were filed by AOPA.

care is a primary commitment,

Amputees attended.

Minutes were allotted per speaker.

changes—that quality of patient

200

Three

Comment submissions were generated via AOPAvotes.org and patient postcards.

returning for discussions with

AOPA representatives delivered statements.

>5,000

EDITOR’S NOTE: To read more about AOPA’s advocacy efforts and the events of August 26, see this issue’s This Just In (page 26) and our cover story (page 30).

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Happenings RESEARCH ROUNDUP

State-of-the-Art Gait Lab Debuts at ASU A Gait Realtime Interactive Analysis Lab (GRAIL) has been installed at the Biomechanics and Motor Control Laboratory (BMCL) at Alabama State University (ASU). The GRAIL, an advanced device for studying human motion—such as prosthetic gait—resembles a cross between a huge video game and a sound stage. Developed in Amsterdam and financed by a $480,000 grant from the U.S. Army Research Laboratory in Adelphi, Maryland, the GRAIL at ASU is one of only six in North America. The GRAIL consists of a wide treadmill attached to a motion base with sophisticated scales that detect the force of each step and an electromyography device that measures how each muscle contracts. The motion capture system is surrounded by a semicircular projection screen. Overhead infrared cameras and seven linked

The Gait Realtime Interactive Analysis Lab is designed to evaluate gait and ultimately improve function while enhancing data collection.

OCTOBER 2015 | O&P ALMANAC

EDITOR’S NOTE: To read more about another advanced biomechanical lab system being used by Brooke Army Medical Center, see this month’s feature on the Center for the Intrepid, page 40.

PHOTOS: David Campbell/Alabama State University

computers also are used to attain users’ motion. Subjects’ legs are fit with small sensors to capture the motion of their ankles and legs as well as the forces at each joint. Lee Childers, PhD, MSPO, CP, director of the BMCL, says the GRAIL will be used to help a wide range of amputees and others. The lab will conduct research with the help of volunteers from throughout the community, some with prostheses. Researchers will focus on how people with amputations or neurological injuries use their remaining motor system to move while wearing a prosthesis or orthosis. They also will research how to improve running performance while minimizing the risk of injury, and will attempt to define how the human nervous, muscular, and skeletal systems interact to solve Bernstein’s problem of motor redundancy. Childers says the new system will be used to “improve people’s lives.… With GRAIL, what used to take weeks of analysis now takes minutes. We hope to use it to do things like improve the design of prosthetic and orthotic devices, enhance physical therapy protocols, and learn fundamental principles that govern how we walk.” Installation of the GRAIL also will improve data collection for prosthetics, which is in demand by payors. The data captured by the new system as amputees move and respond to devices will feed into research studies used to help shape policy and care protocols. “We’ll be publishing our findings as a way of reaching out,” says Childers. “Our main goal is to help people through this great new way to research human motion.”

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HAPPENINGS

STATE STATISTICS

Amputee Coalition Publishes Fact Sheets on Limb Loss By State The Amputee Coalition has published a Fact Sheet Series, displayed as an interactive map, indicating trends and incidence of amputation in several states. Each state Fact Sheet presents the total number of amputations in the state, along with patient demographics. The numbers in the Fact Sheets come from the latest national hospital discharge data. Visit the Amputee Coalition’s website at www.amputeecoalition.org for more information.

Total Number of Amputations Reported in 2012, Select States

14,008

9,532

5,261

4,817

MASSACHUSETTS

MICHIGAN

NORTH CAROLINA

FLORIDA

CALIFORNIA

2,732

Source: Amputee Coalition, www.amputee-coalition.org

OCTOBER 2015 | O&P ALMANAC

WORLDWIDE O&P

Global Market Value for Prosthetics To Slowly Increase By 2021 Consulting firm GlobalData has undertaken a study of the global market value for prosthetics and found the value will rise slowly—from just more than $1 billion in 2014 to approximately $1.21 billion by 2021. Reimbursement difficulties remain the largest obstacle to growth in the prosthetics sector, the firm said. The company’s report, titled “MediPoint: Braces and Supports and Prosthetic Devices—Global Analysis and Market Forecasts,” predicts the increase to occur across the 10 major markets of the United States, France, Germany, Italy, Spain, the United Kingdom, Japan, India, China, and Brazil. The increase represents a compound annual growth rate of 2.6 percent. Emerging technological advancements in prosthetics offer an opportunity for market growth during the forecast period, providing reimbursement issues can be resolved, say report authors. “Recent trends in prosthetics focus on socket design for improved user comfort, as well as enhanced device functionality with less user energy expenditure,” says Jennifer Ryan, GlobalData’s analyst covering medical devices. “Particular attention has been paid to upper-extremity device improvements, due in part to the number of amputees returning from global conflicts…. The increased usage of computer-aided design and 3D printing in prosthetic production opens the market to the possibility of not only

more streamlined production, but also innovative and customized designs.” Procedures that integrate prostheses into a user’s nervous system for optimal device control, including targeted muscle reinnervation and targeted sensory reinnervation, have the potential to drive growth in the prosthetics market, says Ryan, but reimbursement limits access to the the most innovative devices. “Tightening health-care budgets, combined with the extremely high cost of the newest technology, creates complications for payors,” explains Ryan. Both public and private insurers are increasingly emphasizing the requirement for strong clinical evidence before granting reimbursement for advanced prostheses. Despite these challenges, “the combination of an aging global population, growing amputation numbers due to trauma in emerging markets, and diabetic or vascular complications worldwide, as well as an increased awareness of prosthetic users’ needs, will continue to drive the market,” says Ryan.

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HAPPENINGS

CYBER SECURITY

ECONOMIC OUTLOOK

Federal Health-Care Spending on the Rise

Health-Care Organizations Compromised by Cyber Attacks

During the next 10 years, federal spending on Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and exchange subsidies will rise from the current rate of 5.2 percent of the country’s economic output to 6.2 percent in 2025, according to “An Update to the Budget and Economic Outlook: 2015-2025,” a report published by the Congressional Budget Office (CBO) in August.

2015 2025

respondents feel they are adequately prepared to prevent attacks.

5.2% 6.2%

The 2025 estimate is a 0.1 percent adjustment from the previous 2025 prediction, attributed in part to a new federal law. The Medicare Access and CHIP Reauthorization Act of 2015, which was enacted in April and repealed Medicare’s sustainable growth rate for physician payments, led to CBO officials raising Medicare expenses by $159 billion over the next decade. That legislation calls for pay increases of 0.5 percent for physicians during the next four years, followed by six years of flat payment rates. The law also “extended other expiring Medicare provisions and raised premiums for relatively high-income enrollees,” which will result in higher Medicare expenses, according to the CBO report. The CBO also said that federal subsidies for health plans purchased on the Affordable Care Act’s exchanges are expected to cost the government $16 billion less than expected. Instead, more people are likely to obtain coverage through CHIP or Medicaid’s Transitional Medical Assistance program, according to the report.

ONLY HALF of

OCTOBER 2015 | O&P ALMANAC

How secure is the patient and payment data at your facility? In a recent “HealthCare Cybersecurity Survey” conducted by KPMG, 81 percent of health-care executives said their organizations have been compromised by at least one malware, botnet, or other cyber attack during the past two years. Only half of respondents feel they are adequately prepared to prevent attacks. Survey participants included 223 chief information officers, chief technology officers, chief security officers, and chief compliance officers at health-care providers and health plans. KPMG found that the number of attacks is increasing: Thirteen percent of respondents reported being targeted by external hack attempts about once a day, and 12 percent reported two or more attacks per week. In addition, 16 percent of health-care organizations said they cannot detect in real time if their systems are compromised. “The vulnerability of patient data at the nation’s health plans and approximately 5,000 hospitals is on the rise, and health-care executives are struggling to safeguard patient records,” says Michael Ebert, leader in KPMG’s

Healthcare & Life Sciences Cyber Practice. “Patient records are far more valuable than credit card information for people who plan to commit fraud, since the personal information cannot be easily changed. A key goal for execs is to advance their institutions’ protection to create hurdles for hackers.” The most frequently reported form of cyber attacks is malware, which is software designed to disrupt or gain access to private computer systems, according to 65 percent of survey respondents. Twenty-six percent of respondents cited botnet attacks, where computers are hijacked to issue spam or attack other systems, and another 26 percent cited “internal” attack vectors, such as employees compromising security. Areas with the greatest vulnerabilities within a health-care organization include the following: • external attackers, 65 percent • sharing data with third parties, 48 percent • employee breaches, 35 percent • wireless computing, 35 percent • inadequate firewalls, 27 percent.

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HAPPENINGS

O&P ATHLETICS

Iowa City Golf Tournament Draws Veterans

RESEARCH ROUNDUP

Paralysis Therapy Paired With Robotic Exoskeleton Found To Improve Patient Function

PHOTOS: Courtesy of U.S Department of Veterans Affairs

OCTOBER 2015 | O&P ALMANAC

Mark Pollock with trainer Simon O’Donnell

of functional capability that remains,” Edgerton says. “But it has to do some relearning” via electrical stimulation. “We think the future in robotics and rehabilitation is that the device will assist but will not completely take over, so the person has to regain some voluntary movement and to assist the device in making voluntary movements,” says Edgerton. “The robot will do less and less, and the subject will do more and more.”

PHOTOS: Courtesy of Mark Pollock; V.Reggie Edgerton: Reed Hutchinson/UCLA

More than 200 participants recently took part in the National Veterans Training, Exposure, and Experience Tournament, one of the nation’s top adaptive golf events for blind and disabled veterans. The tournament was held September 7-11 at several golf courses in the Iowa City area, including Lake McBride, Kalona Country Club, West Liberty Country Club, Elks Country Club, and Blue Top Ridge golf courses. In addition to golfing, participants also were invited to try other adaptive sports, such as bowling, kayaking, horseback riding, tandem biking, fishing and frisbee golf. The event was hosted by the Iowa City Department of Veterans Affairs Health-Care System, with sponsorship support from Veterans Canteen Service and others.

Researchers at the University of California—Los Angeles (UCLA) have tested the combination of a bionic suit worn after transcutaneous spinal cord stimulation to improve the movements of paralyzed subjects. UCLA has reported that its initial study participant, Mark Pollock, underwent stimulation to selected sites over the spinal vertebrae during a week of training, which was designed to improve his muscle movement, cardiovascular function, and muscle tone. Then he wore a batteryoperated exoskeleton designed to enable paralyzed patients to move their legs in a step-like fashion. During the first five days of physical training, Pollock successfully took thousands of steps. Pollock also reported feeling tension in his legs for the first time since he became paralyzed, and felt his legs “join in with the movement” of the bionic suit. Researcher V. Reggie Edgerton, professor of integrative biology and physiology, neurobiology, and neurosurgery, presented the case findings in Milan, Italy, in late August. He V. Reggie Edgerton reported that the electrical stimulation to the spinal cord appears to reawaken neurons, which appear to recognize sensations sent up by moving the limbs and respond. The combination of stimulation therapy and the bionic suit provides painless stimulation using special kinds of electrical pulses at a high frequency, which may help improve movement in individuals with chronic paralysis. “After the injury, there’s a lot

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PEOPLE & PLACES PROFESSIONALS

BUSINESSES

IN MEMORIAM

ANNOUNCEMENTS AND TRANSITIONS

Shubert Chang, CPO

Shubert Chang, CPO, owner and president of Dynamic Orthopedics Inc. in Davie, Florida, passed away August 23 at the age of 47 from heart failure. Chang, who lost his left leg in a motorcycle accident at the age of 15, graduated from Florida International University with a bachelor of science in prosthetics and orthotics in 1992. He opened Dynamic Orthopedics with his wife, Melisa, a physical therapist, in 2002. Chang was considered one of Florida’s top pediatric prosthetist/orthotists, and had treated more than 10,000 children, many with special needs. He was known to travel to see patients who could not come into his office. He also lectured for Nova Southeastern Physical Therapy Program and Broward Community College Physical Therapy Assistant Program. Chang is survived by his wife, Melisa, owner and vice president of Dynamic Orthopedics, and their two daughters.

Ferrier Coupler Options!

The National Association for the Advancement of Orthotics & Prosthetics has announced two additions to its board of directors. Gordon Stevens, CPO, and Mike Rayer, CP, have joined the organization’s board of directors for the 114th Congress (2015-2016). Stevens is president of Baker O&P Texas, a partner practice of Bulow Clinic Partners Group. He sits on the advisory board for Ottobock and Össur. Rayer is the managing partner for Prosthetic Innovations in Crum Lynne, Pennsylvania. He also is a board member for the i2N network, which promotes the growth of emerging businesses in southeastern Pennsylvania.

Interchange or Disconnect

The Ferrier Coupler provides you with options never before possible:

Enables a complete disconnect immediately below the socket in seconds without the removal of garments. Can be used where only the upper (above the Coupler) or lower (below the Coupler) portion of limb needs to be changed. Also allows for temporary limb replacement. All aluminum couplers are hard coated for enhanced durability. All models are interchangeable.

Model A5

Model F5

Model P5

The A5 Standard Coupler is for use in all lower limb prostheses. The male and female portions of the coupler bolt to any standard 4-bolt pattern component.

The F5 Coupler with female pyramid receiver is for use in all lower limb prostheses. Male portion of the coupler features a built-in female pyramid receiver. Female portion bolts to any standard 4-bolt pattern component. The Ferrier Coupler with an inverted pyramid built in. The male portion of the pyramid is built into the male portion of the coupler. Female portion bolts to any 4-bolt pattern component.

OCTOBER 2015 | O&P ALMANAC

Model FA5

Model FF5

Model FP5

NEW! The FA5 coupler with 4-bolt and female pyramid is for use in all lower limb prostheses. Male portion of coupler is standard 4-bolt pattern. Female portion of coupler accepts a pyramid.

Model T5

NEW! The FF5 has a female pyramid receiver on both male and female portions of the coupler for easy connection to male pyramids.

NEW! The FP5 Coupler is for use in all lower limb prostheses. Male portion of coupler has a pyramid. The Female portion of coupler accepts a pyramid.

The Trowbridge Terra-Round foot mounts directly inside a standard 30mm pylon. The center stem exes in any direction allowing the unit to conform to uneven terrain. It is also useful in the lab when tting the prototype limb. The unit is waterproof and has a traction base pad.

REIMBURSEMENT PAGE

By DEVON BERNARD

Suspended Privileges

E! QU IZ M EARN

Learn how to prevent your Medicare billing privileges from being revoked

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 24 to take the Reimbursement Page quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.

N FEBRUARY 2011, CMS published its final rule covering new enrollment requirements, and these new rules became effective March 25, 2011. Part of the new enrollment requirements granted the National Supplier Clearinghouse (NSC), and its agents, more tools to ensure compliance with Medicare guidelines and the 30 Supplier Standards. One of these tools was the ability to make unscheduled/unannounced site visits. With the increased use of unannounced site visits, we are hearing more stories of Provider Transaction Access Numbers (PTANs)/supplier numbers and Medicare billing privileges being deactivated and, in some cases, revoked. According the Code of Federal Regulations (42 CFR 424.535), which was updated in 2011 and 2012 to be in line with some of the new enrollment procedures, there are 11 possible reasons Medicare billing privileges may be revoked. Some of these reasons may affect orthotic and prosthetic providers, even if you are unaware that you are doing something wrong, and some of them may never apply to you and your business. Either way, it is important for you to be aware of them.

Reasons for Revocation

Let’s look at the 11 reasons that you might lose your ability to bill Medicare, so you can guard against them. Noncompliance. The provider or supplier is determined not to be in compliance with the enrollment requirements described in this section, or in the enrollment application applicable for its provider or

OCTOBER 2015 | O&P ALMANAC

BUSINESS CE

CREDITS P.24

supplier type, and has not submitted a plan of corrective action. The provider or supplier also may be determined not to be in compliance if it has failed to pay any user fees as assessed. An example of a failure to comply with enrollment requirements could be to let your insurance or your surety bond lapse for any reason. If your liability insurer or surety bond holder notifies the NSC that this has happened, it will consider you in noncompliance, which could result in revocation if you cannot fix the situation in a timely manner, i.e., obtain a new bond or new insurance. Supplier conduct. The supplier, or any owner, managing employee, authorized or delegated official, or other health-care personnel of the supplier, is excluded from Medicare, Medicaid, or any other federal health-care program, or is debarred, suspended, or otherwise excluded from participating in any other federal procurement or nonprocurement program. To ensure compliance and to prevent having your billing privileges revoked, verify that all employees (new and old) are not excluded from any federal programs. Check the Office of the Inspector General exclusion list at http://exclusions.oig.hhs.gov/.

Felonies. The supplier, or any owner of the supplier, within the 10 years preceding enrollment or revalidation of enrollment, was convicted of a federal or state felony offense that CMS has determined to be detrimental to the best interest of the program and its beneficiaries

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REIMBURSEMENT PAGE

to continue enrollment, including the following: • Felony crimes against persons; • Financial crimes, such as extortion, embezzlement, income tax evasion, and insurance fraud; • Any felony that placed the Medicare program or its beneficiaries at immediate risk, such as a malpractice suit that results in conviction of criminal neglect or misconduct; and • Any felonies that would result in mandatory exclusion under section 1128(a) of the Social Security Act. False or misleading information. The supplier has certified as “true” misleading or false information on the enrollment application.

On-site review. CMS determines upon an on-site review that the supplier is no longer operational to furnish Medicare-covered services, or the supplier has failed to satisfy any or all of the Medicare enrollment requirements. This is the most likely reason for which you may have your billing privileges revoked. In essence, it means you failed an on-site inspection. There are several reasons for a failed site inspection, but the most likely is the result of not meeting the Supplier Standards (e.g., not posting your hours or not having a proper complaint protocol in place).

Grounds related to provider and supplier screening requirements. This would be applicable when an institutional provider does not submit an application fee or hardship exception request that meets the requirements set forth in §424.514 with the Medicare revalidation application, or the hardship exception is not granted and the institutional provider does not submit the applicable application form or application fee within 30 days of being notified that the hardship exception request was denied. This reason also would be applicable in the following scenarios: • CMS is not able to deposit the full application amount into a government-owned account.

OCTOBER 2015 | O&P ALMANAC

• The funds are not able to be credited to the U.S. Treasury. These conditions would hold if the provider or supplier lacks sufficient funds in the account at the banking institution whose name is imprinted on the check or other banking instrument to pay the application fee, or if there is any other reason why CMS or its Medicare contractor is unable to deposit the application fee into a government-owned account. Misuse of billing number. The provider or supplier knowingly sells or allows another individual or entity to use its billing number.

The

first step

in fighting a possible revocation is to create and submit what is known as a

Corrective Action Plan (CAP). Abuse of billing privileges. The provider or supplier submits a claim or claims for services that could not have been furnished to a specific individual on the date of service. These instances include but are not limited to situations where the beneficiary is deceased, the directing physician or beneficiary is not in the state or country when services were furnished, or when the equipment necessary for testing is not present where the testing is said to have occurred.

Failure to report. The provider or supplier did not comply with the reporting requirements specified in §424.516(d) (1) (ii) and (iii) of this subpart. This means that the provider or supplier did not notify Medicare within 30 days of any adverse legal action or of any change in your practice location (i.e., change of address, change of ownership, change of hours, changes in products/services, etc.).

Failure to document or provide CMS access to documentation. The provider or supplier did not comply with the documentation or CMS access requirements. This means that you must maintain all documentation for seven years from the date of service, and that, upon request from CMS or any of its approved contractors, you must provide this documentation.

Initial reserve operating funds. CMS or its designated Medicare contractor may revoke the Medicare billing privileges of a home health agency and the corresponding provider agreement if, within 30 days of a CMS or Medicare contractor request, the home health agency cannot furnish supporting documentation verifying that the HHA meets the initial reserve operating funds requirement.

Responding to Revocation

If it is determined that your billing privileges will be revoked, what will happen, and what can you do to prevent it from happening? Prior to revocation, you should receive a notice—usually a certified letter—outlining why your billing privileges are about to be revoked, and when the revocation will take effect. The revocation date will typically occur within 30 days of the postmarked date on the letter. However, your revocation is not 100 percent automatic; you may appeal the revocation and possibly even stop it before it happens. The first step in fighting a possible revocation is to create and submit what is known as a Corrective Action Plan (CAP). The CAP must be submitted within 30 days of the postmarked date

REIMBURSEMENT PAGE

on the letter of revocation. You may submit a CAP if you can show that the NSC has made a factual mistake in its review and/or the noncompliance issued cited in the revocation letter has been addressed and corrected, and you should include assurances that you will comply in the future as well. There are certain instances when a CAP will not be accepted and you will have to go to the next level. For example, if your billing privileges are being revoked because of supplier conduct or felonies (Reason 2 or 3 above), you may not submit a CAP. The next step in fighting a revocation of billing privileges is to file a reconsideration request within 60 days of the postmarked date on the letter of revocation. A reconsideration request asks for an on-the-record hearing conducted by a hearing officer who was not involved in the initial decision to deny or revoke billing privileges. Upon the receipt of a reconsideration request, NSC will forward all of the relevant information to the hearing officer, who will then schedule, conduct, and render a decision. Your request should include a cover letter that states the issues or the findings of fact with which you disagree and the reasons for disagreement. Since the reconsideration will be conducted on the record, you should submit all documentation needed to prove your compliance. If you fail to submit all evidence before a decision is made, you will not be allowed to submit new evidence at a higher appeal level. If your reconsideration is not successful, you still have the option of an administrative law judge review, and then a Departmental Appeals Board review. During the appeals process, no payments may be made to you. However, if your revocation is reversed, your billing privileges will be retroactive to the date the revocation was effective, and you may resubmit any unpaid claims that were incurred while the revocation was in effect. If your appeals are unsuccessful and your billing privileges are revoked, you will have to wait between one and three years before reapplying and re-enrolling in the Medicare program. 24

OCTOBER 2015 | O&P ALMANAC

Failure to report a change. The provider or supplier does not report a change to the information supplied on the enrollment application within 90 calendar days of when the change occurred. Changes that must be reported include, but are not limited to, a change in practice location, a change of any managing employee, and a change in billing services. Certain other changes, such as changes in ownership or control, must be reported within 30 calendar days.

When your billing privileges are deactivated for failure to report a change, you must submit a new enrollment application, including paying the application fee, to reactivate your billing privileges.

Losing Billing Privileges

Aside from revocation, some providers face having their billing privileges suspended. There are two main reasons why billing privileges may be deactivated. Infrequent claim submission. The provider or supplier does not submit any Medicare claims for 12 consecutive calendar months. The 12-month period begins the first day of the first month without a claims submission and ends the last day of the 12th month without a submitted claim. Each location where you see and treat patients must have its own PTAN/ supplier number, and each location must submit at least one claim under its PTAN/ supplier number at least once within four consecutive quarters. If your billing privileges were deactivated because of a failure to file a claim, you may challenge the deactivation and show that there was proof of billing during the last cycle or the time period in question. However, if you cannot demonstrate that you submitted a claim during the time period in question, then you will need to re-enroll with Medicare. This means completing a new 855S application, paying the application fee (currently $553), and showing compliance with all the other enrollment standards.

Focus on Prevention

No one wants to go through the hassle, hurdles, time, and expense of having billing privileges revoked or deactivated, and having to fight to get them back. Not only can it be costly in the loss of revenue from nonbilling, it also may cause you to lose patients. Make sure that you and your staff are familiar with the Medicare Supplier Standards, Medicare enrollment requirements, and reimbursement policies; always keep an eye out for any announcements from CMS; and donâ&#x20AC;&#x2122;t let important notices get buried or lost in the day-to-day operations of your business. Devon Bernard is AOPAâ&#x20AC;&#x2122;s assistant director of coding and reimbursement services, education, and programming. Reach him at dbernard@aopanet.org. Take advantage of the opportunity to earn two CE credits today! Take the quiz by scanning the QR code or visit bit.ly/OPalmanacQuiz. Earn CE credits accepted by certifying boards:

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This Just In

Strength in Numbers Experts from across the allied health-care professions showed their support for AOPA’s position regarding the proposed LCD

HERE’S ALWAYS A WRAP-UP after a great event, and while everyone was energized by the April 26 hearings and patient rally opposing the durable medical equipment Medicare administrative contractors’ (DME MACs’) proposed revisions to the Local Coverage Determination (LCD) and Policy Article on Lower-Extremity Prostheses, follow-on activities also will contribute to the final decision. Leading up to the patient rally, AOPA Executive Director Tom Fise, JD, wrote to Secretary of Health and Human Services (HHS) Sylvia Burwell on August 21 to notify her of the scheduled patient rally in front of the HHS headquarters building, and offered that representatives of AOPA and the amputee community would be available to meet with her sometime during the rally. An email at 7:23 a.m. on the morning of the August 26 rally from Sharon Lewis, senior disability advisory to Secretary Burwell, responded to the offer by saying:

“As requested by Mr. Fise, several senior members of the HHS staff would like to meet with you as representatives of the amputee community when you are over in front of HHS for the rally tomorrow. We would like to hear your concerns about the proposed changes initiated by the DME MACs related to Local Coverage Determinations for lower-limb prosthetics. 26

OCTOBER 2015 | O&P ALMANAC

This Just In

“Members of the HHS team in attendance will include Acting CMS Administrator Andy Slavitt; CMS Deputy Administrator Patrick Conway; Senior Counselor Kevin Thurm, and myself.” The 4 p.m. meeting with the receptive and interested HHS team was very cordial. In attendance representing AOPA were Fise, AOPA President Charles H. Dankmeyer Jr., CPO, Adrianne Haslet-Davis, and Tom Watson, CP. In addition, Dave McGill and Peter Thomas, JD, from the National Association for the Advancement of Orthotics and Prosthetics, and Jack Richmond, CPOA, CFo, and Sue Stout of the Amputee Coalition, took part in the discussion—in total, there were eight representatives, five of whom are amputees. The meeting concluded with the CMS representatives promising further conversations with the DME MAC contractors on the

proposal, stating that “cost savings are not a justification for LCD changes.” Consistent with AOPA’s concern that Medicare’s action affected all amputees because private insurers usually follow Medicare’s lead on reimbursement, an August Medical Policy Update by United Healthcare asserts that as of Oct. 1, 2015, vacuum pumps for residual-limb volume management would be considered “…unproven and not medically necessary.” The United Healthcare announcement prompted Fise to write to Slavitt citing the announcement as a “very unfortunate example of just how quickly commercial adoption can ensue from even a preliminary indication by CMS and/or its contractors,” of any reduction of Medicare benefits. Further efforts are underway urging United Healthcare to rescind its policy eliminating coverage for vacuum pumps. So much was going on in the final days before the August 31 comment deadline that some very notable

developments may have escaped widespread notice. One effort that registered big time in the media was the joint letter to the DME MACs signed by nine researchers, stating, in part, the following: “It has recently come to light that the bibliography that was associated with the decision-making process for this draft LCD included papers that we had authored. “We would like to go on record as stating that the works referenced do not support any of the changes outlined in the CMS proposal. In addition, many of the citations in the CMS bibliography are not peer reviewed, are not current, or are not true citations in accordance with referencing standards by recognized entities. “The proposed changes described in DL#33787, in our expert opinion, would diminish both the quality and access to prosthetic care across our nation. We, as the experts cited in this document, wish to go on record as strongly opposing the draft LCD.”

O&P ALMANAC | OCTOBER 2015

This Just In

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Medicare, please don’t disable us! Further support for rescinding the proposed Policy Article came from allied health-care professionals who also called for rescinding the proposal. A letter facilitated by AOPA Board Member Don Shurr, CPO, PT, signed by three past presidents of the American Academy of Orthopaedic Surgeons, echoed the researchers’ concerns, saying, “By and large, the items listed in this bibliography do not relate to, and certainly do not support, the very dramatic departures from standard of care posited in the proposal, and several of the authors whose works are referenced in that bibliography have been quick to assert they cannot support either the LCD’s proposed policies nor the use of their publications as germane to these proposals.” The American Academy of Physical Medicine and Rehabilitation (AAPM&R) took a strong stand on an issue close to every O&P clinician’s 28

OCTOBER 2015 | O&P ALMANAC

heart when it said in its formal comments: “Prosthetists provide a service in the care of people with amputations, and it is not clear why their documentation cannot be considered a part of or, at a minimum, used in conjunction with, the medical record. Prosthetists don’t just deliver a product—they participate in or perform many of the tasks needed to determine the best prosthetic for a patient and, as such, their documentation should be treated with the same respect as any other professional. Refusing to use their notes in reviewing the medical necessity of a claim is both insulting to the prosthetist and wastes the physician’s limited time.” We couldn’t have said it better! AAPM&R went on record regarding the assistive device provisions by saying, “Using such an assistive device as part of criteria to limit what kind of prosthesis a patient may qualify for, is

directly counter to the principles on which rehabilitation is established. Too often, a person who has been in an accident or becomes ill is unable to return to [his or her] former way of doing things. Through rehabilitation, we assist such patients in developing new ways to accomplish the functional tasks that are important to them; it does not matter if he or she needs an assistive device, whether it be a cane for safety or forearm crutches for added stability, as long as the assistive device makes it easier or even possible to achieve functional goals they were previously unable to do.” Charles L. Saltzman, MD, a former president of the Association of Bone and Joint Surgeons and the American Orthopaedic Foot and Ankle Society, and current president of the International Federation of Foot and Ankle Societies, made clear he was not writing in an official capacity but as an individual “who has serious concerns with respect to a recent rulemaking proposal (DL33787) under the auspices of CMS, which, if implemented, I believe would do serious harm to Medicare and the patients I serve.” Benjamin J. Miller, MD, MS, wrote the DME MACs: “Unfortunately, the proposals lack any evidence to support the changes. These proposals, if implemented, would dramatically reduce access to the current standard of prosthetic care and force Medicare patients to accept 1970s technology.” As of this writing, final word on what the DME MACs will do on the proposal isn’t clear, but the uproar created in the amputee community and with allied health-care groups sends a strong message that the policy proposals are clearly far off the mark and would seriously harm not just Medicare beneficiaries but all amputees. AOPA did everything in its power to help make sure that message came through loud and clear to CMS and the DME MACs, and more than 400 media placements—along with AOPAcreated TV spots, print ads, and social media—all were designed to support the message.

COVER STORY

WE STAND

DETERMINATION AND STRENGTH DEFINE THE PEOPLE WHO RALLIED AGAINST THE LCD LOWER-LIMB PROSTHETIC PROPOSAL

OCTOBER 2015 | O&P ALMANAC

COVER STORY

NEED TO KNOW On July 16, 2015, the four DME MACs published a draft Local Coverage Determination (LCD) and Policy Article governing Medicare coverage of lower-limb prostheses. If enacted, this policy would dramatically and adversely impact care for U.S. amputees, effectively reverting to the standard of care and limb technology of the 1970s. AOPA responded immediately, mobilizing members, allies, and advisors to work on multiple strategies, with the goal of requesting that the draft policy be rescinded. AOPA spearheaded an initiative that generated more than 5,000 comments from patients, practitioners, and other interested parties, which were included in the official record for LCD rule-making. AOPA also submitted 43 pages of comments regarding the draft policy. AOPA conducted a data analysis demonstrating that the data used by CMS contractors to support their proposed policy was based on outdated information. In addition, several of the authors cited in the DME MAC’s bibliography refuted the recommendations in the LCD. AOPA’s initiative hit the mainstream media with a series of print and television advertising campaigns, as well as a series of patient vignettes communicating the personal impact of the proposed LCD on patient care. On August 26, AOPA arranged for five speakers at the DME MAC public meeting in Linthicum, Maryland, then organized a patient rally at HHS headquarters. At the rally’s conclusion, representatives from AOPA, the O&P Alliance, and the Amputee Coalition met with high-ranking CMS officials who said they would work with the regional contactors’ medical directors. They explained that their policy would be supported by clinical evidence and would not limit necessary service for Medicare beneficiaries. While the outcome of these efforts on the proposed LCD is unknown as of this publishing, AOPA and other O&P stakeholders are hopeful, believing that their efforts to call attention to the problems with the proposed LCD will have a significant impact on the ultimate decision regarding the proposed policy.

O&P ALMANAC | OCTOBER 2015

COVER STORY

ADVOCACY, EXPLAINED

HEY CARRIED SIGNS AND

JUL 2015

Events Timeline

JULY 21

JULY 16 DME MACs release joint proposal for substantial modifications to the LCD and Policy Article applicable to Medicare reimbursement for lowerextremity prosthetics.

AOPA website and MobilitySaves.org are updated with need-toknow information for members and patients.

AUGUST 10 First “patient vignette” highlighting the proposed LCDs’ impact on patient care launch on social media.

First meeting

Amputee and former

with CMS Deputy Director Sean Cavanaugh takes place.

AUGUST 13

AUGUST 11

Six physician organizations submit letters to CMS and DME MACs expressing grave concern for the proposed LCDs.

AUGUST 16

bullhorns, they wore conspicuous orange shirts, and they united their voices to oppose regulators whose proposal would significantly diminish quality of life for the nearly 2 million amputees living in the United States. William Guaragno, CPO, of Next Step Technologies in Danbury, Connecticut, was one of the 150 O&P professionals and amputees who rallied on behalf of patients and O&P businesses in front of the U.S. Health & Human Services building in Washington, D.C., on August 26. “It’s going to be nasty,” he said of Medicare’s proposed changes to reimbursement for lower-limb prosthetic care. “We are going to get rid of the technology that we have been using since the early 1990s, and if that happens, amputees are not going to have a full life. Their activities of daily living are going to subside, and they are going to be sitting in a wheelchair more because they will not have the use of technology or silicone liners to get them through the day,” he said. Less activity can mean a shorter lifespan, explained Guaragno. “[Amputees] need to be able to get up and walk. We’ve removed a lot of barriers with the Americans With Disabilities Act, and…to get rid of the high-tech [devices] that we use to get these people to walk right away—it’s going to be sad.”

AOPA explains how CMS data refutes need for LCD policy change.

U.S. Senator Bob Kerrey sends letter

to Sylvia Mathews Burwell, HHS secretary, denouncing the proposed LCDs. Request for change in DME MAC policy of proof of delivery is submitted to CMS.

AOPAVotes.org records 1,100+ O&P/AOPA member letters and nearly 2,100 patient letters to the DME MACs and congressional representatives.

AUGUST 19

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Medicare

OCTOBER 2015 | O&P ALMANAC

able us!

don’t dis

AOPA and the Amputee Coalition issue joint press release on the “significant setback” of proposed LCDs.

AOPA and the O&P Alliance hold first of seven meetings to create comments for official response.

COVER STORY

JULY 31

AOPA submits request to DME MACs for the required scientific evidence to support recommended policy changes absent from original publication.

“We the People” White House petition is initiated by NAAOP President & AOPA Board Member Dave McGill;

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AUG 2015

SEPT 2015

Comment period closes. AOPA, working with the

Amputee Coalition, stimulates 1,138 comments from patient postcards; 2,548 from patient AOPAVotes; and 1,380 from member AOPAVotes.

AUGUST 31

Comprehensive analysis of the LCD proposal is released; AOPA board creates and approves action plan to respond.

JULY 29

SEPTEMBER 1

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PRESS ADVISORY SESSION IS HELD; Boston Marathon bombing amputee Adrianne Haslet-Davis, Sen. Kerrey, AOPA, and Amputee Coalition are among the participants.

AUGUST 25

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AUGUST 23

AUGUST 24

PR efforts focusing on the “Glass Ceiling of Prosthetics” launch on MobilitySaves.org, print, and broadcast media outlets, including ABC, CNN, Fox News, CSNBC, , and .

Nine researchers challenge the absence of scientific/medical/ literature support for the LCDs; request such information from DME MACs.

participants provide statements at the DME MAC meeting in Linthicum, Maryland, five of whom represent AOPA.

AUGUST 28 AOPA submits

43-page response to the DME MACs.

Afternoon amputee demonstration is held at the HHS building in DC; 150 people participate. Later, eight members of AOPA/O&P Alliance and Amputee Coalition meet with senior HHS officials.

O&P ALMANAC | OCTOBER 2015

COVER STORY

Hill said she was a former “union leader” who understands solidarity. She learned about the rally plans via social media and decided to make the roughly seven-hour trip to unite with other supporters out of concern not only for her personal situation but also for the domino-like effect the proposal’s tighter access to care and devices would have on the broader community. “This is going to affect more than just the amputees, but also their families, friends, and employers—in the long run, it’s going to affect us all,” she said. “People are going to lose jobs, and a lot of us are going to lose our independence.” O&P professionals in attendance expressed concern for their patients, as well as for their patient-care facilities and manufacturers, which would likely cease research and development efforts if funding for high-tech devices is cut. “Absolutely, businesses are going to die off if patients are only able to get one leg every five years, and not have access to the high-tech feet and knees,” Guaragno said.

Possibilities and Potential

Andrea Hill Andrea Hill, a double amputee from Rochester, New York, could be one of those people affected. She lost both of her legs below the knees more than two years ago to complications from diabetes. “I had toes that were amputated and were not healing, so the best thing to do to save my life was to amputate below the knees.” For Hill, who uses a wheelchair for assistance and also has a heart condition, passage of the proposal would mean total denial of the type of prosthetics she uses now—including adjustments to her current devices—due to her pre-existing health issues and use of assistive devices. “Fortunately, I have what I have, but with time your body changes and the shape of your legs changes,” she explained. “I would end up in a wheelchair, and not able to do things that I can do now, like going to festivals or being here.” 34

OCTOBER 2015 | O&P ALMANAC

Some rally participants explained amputees’ prospective loss of independence in terms of limited potential and vulnerability. Carla Craft, business manager at Virginia Prosthetics & Orthotics in Roanoke, helped organize a 4 a.m. charter bus to bring 20 patients and six staffers to the rally and the morning public hearing with DME MAC medical directors in Linthicum, Maryland.

There, she says, several amputees explained how access to new technology allows them to maintain employment. “We can’t go backwards and take that technology away from them. These amputees want to work, they want to be productive community ambulators,” she said. “Amputees change physically and mentally. But if we are able to use the best technology appropriate for those patients, we can prove that they can still function and be as active as they want to be or need to be in order to maintain their job.” Among the participants from Virginia P&O was a 4-year-old girl named Miracle who was born at 22 weeks and had bilateral clubfeet, said Craft. Miracle had her left leg amputated below the knee last year, allowing her to walk for the first time. “I thought about what the future held for her and especially what her future would be if CMS passed the proposed changes. …We are not just fighting for the financial impact the changes would have on our company, but we are fighting for what is the right thing to do,” said Craft. In 2010, Bruce Daugherty of Colorado Springs, Colorado, elected to have his right leg amputated below the knee, also due to clubbed foot. It took him two days to drive the more than 1,700 miles one-way to attend the rally. He wore a prosthesis with a graphic “Can’t never did anything” he designed in honor of his father, who used the phrase to motivate Daugherty as a child.

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Theresa Sareo This was Daugherty’s first long trip alone since his surgery, but attending the rally in person was important to “exercise my First Amendment rights,” he said. “I explained how these higher-functioning prosthetics give me the freedom and ability to do things that I had never been able to do. Part of my decision to have an amputation was because of the advancement of prosthetics out on the market today,” he said. “We need this care, we need access to this care,” said Theresa Sareo, a singer and songwriter from New York who also participated in the event. “We are surviving every single day—we are in recovery every single day of our lives.” Thirteen years ago, a drunk driver struck Sareo while she was crossing an intersection in Manhattan. As a result of injuries, she lost her right leg and hip joint. Sareo said she came to the rally to explain to lawmakers how she must compensate for her ankle, knee, and hip joint. She also wanted to speak out on behalf of female amputees. “We are one of the most vulnerable populations in this country, and to attack us in this way is nothing short of a disgrace,” she told the crowd. “Trauma recovery does not end when they hand you a prosthetic leg; it goes on and on. Part of the blessing of 36

OCTOBER 2015 | O&P ALMANAC

Terri Ross surviving these tragedies is being able to be with people like you and to have this opportunity to [come together] and to speak out. I pray that these provisions can be stopped.” Like Sareo, amputee Scott James came to D.C. to share how prosthetic technology has enhanced his life: “I have been able to live the life that I lead and do the things that I do because no one said I couldn’t,” said James, who lost his leg to childhood cancer 34 years ago. “No one limited me to the technology that I had.”

‘They Will Follow’

Terri Ross of Paducah, Kentucky, traveled from the western part of the state to make her feelings known about prosthetic resources for individuals. A left below-the-knee amputee of 12 years, she said she was functionally limited by wearing a basic prosthesis. But she eventually found a prosthetist who fit her for a K4 prosthetic limb, which enables her now to “do almost anything” physically. Ross said she is concerned her private insurance will “quickly follow suit” of the regulators’ proposal to limit access to devices like the one she wears. At the morning meeting with CMS, Rob Rieckenberg, an insurance advisor and director of client advocacy for Wiggle Your Toes in Bloomington,

Rob Rieckenberg Minnesota, said he asked the attending congresspersons what type of prosthetic coverage they had, and “not a single one” could explain his or her coverage. Rieckenberg, who lost his right leg above the knee in 2005, said his state’s insurance carriers each have different levels of coverage. “Some cover pretty much anything you want, and one caps the coverage at $10,000—that’s it. “A lot of [people] don’t understand that if Medicare does it, all the other insurance carriers will follow,” Rieckenberg explained. “There is a parity bill that has been passed in 17 states, and it is based on Medicare coverage. The parity bill makes every insurance carrier in that state have the same coverage as Medicare—it becomes the standard. If they change that, I honestly don’t know what is going to happen in all of those states.” Heather Abbott of Rhode Island expressed a similar concern regarding existing coverage and access to ongoing care in the future. “Marc and I both lost our legs in the Boston Marathon bombing,” explained Abbott, who had her left leg amputated below the knee. Abbott had arrived with Marc Fucarile of Boston, who lost his right leg and severely injured his left in the bombing. She described how quickly she came to depend on her prostheses to

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Heather Abbott Marc Fucarile regain her active lifestyle—and also how expensive they are. “To learn that there are laws being proposed to potentially take some of that away is really upsetting,” Abbott said. “We came here today to make sure that doesn’t happen. Some day, I’m going to be relying on Medicare, and I want to be as active as I am right now.” “I have a little boy, so chasing a kid around in a wheelchair doesn’t work well in the yard,” said Fucarile, who walks with the assistance of two canes. “But what really offends me is these people are making decisions for people, and they have no idea who they are or what their life is about. They put you in brackets based on what they think you can or can’t do. I think it is kind of ridiculous.” “People need to pay attention to this,” Fucarile concluded. “Just because you are not an amputee today doesn’t mean that you won’t be tomorrow.” Josephine Rossi is editor of O&P Almanac. Reach her at jrossi@contentcommunicators.com.

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Center for the Intrepid offers inclusive, accelerated care for military heroes NEED TO KNOW • The Center for the Intrepid at Brooke Army Medical Center was built eight years ago to offer comprehensive and exceptional O&P care to return military amputees and those with severe extremity injuries to their highly active lifestyles—including, in some cases, active duty. • Prosthetists and orthotists work alongside orthopedic surgeons, occupational and physical therapists, and technicians in a team approach, with the goal of putting a comprehensive plan in place within the first several days of a patient’s stay. • Patients practice everyday skills during therapy in CFI’s “ADL apartment,” which simulates a typical home and features a fully equipped kitchen, laundry, bath, and living room. Clinicians and therapists can monitor patients’ movements and immediately adapt equipment as needed. • CFI houses a fully immersive virtual reality system: the Computer-Assisted Rehabilitation Environment (CAREN). The system features a 21-foot dome and seven high-definition cameras projecting onto a 300-degree screen, with a treadmill, floor sensors, and body-con motion sensors, allowing clinicians to gather highly targeted data under a variety of conditions. • Fabrication takes place onsite in a full-production prosthetic lab with eight technicians. The space offers computer-assisted technology, wireless technology for remote adjustment of high-tech prostheses, and the latest materials, such as acrylic resins, carbon fiber composites, and titanium.

OCTOBER 2015 | O&P ALMANAC

Center for the Intrepid, San Antonio, Texas

PHOTO: Courtesy of the U.S. Army

HE PACE OF TECHNOLOGICAL advancements in O&P has picked up significantly over the past decade, with new designs and high-tech devices enabling patients to function at levels previously unattainable. Much of the innovation has been driven by a desire to restore function to the increased number of service members experiencing amputations and limb injuries during the Operation Iraqi Freedom and Operation Enduring Freedom conflicts. This “drive to restore function” can be seen clearly at the Center for the Intrepid (CFI), under the command and control of the Brooke Army Medical Center (BAMC) in San Antonio, Texas. At CFI, military patients are treated in an efficient manner under a team approach, with prosthetists, orthotists, surgeons, therapists, and technicians working together using the latest technologies in a high-tech environment. This approach has enabled hundreds of military patients to return to highly active lifestyles—including, in some cases, active duty—and serves as an example of premier O&P care that can be emulated in the civilian patient base.

Optimal O&P Treatment Design

A whole new era of prosthetic and orthotic care for military casualties who sustained amputation, burns, or functional limb loss began in February of 2007, when the four-story, 65,000-square-foot outpatient rehabilitation facility known as CFI opened its doors.

O&P ALMANAC | OCTOBER 2015

A patient uses CFI’s 21-foot climbing tower with auto-belay to promote strengthening, agility, and aerobic conditioning.

Physical and occupational therapists are on hand to conduct detailed evaluations and determine new strategies for the best care. A patient uses the AntiGravity Treadmill to analyze human motion, with particular emphasis on amputee gait. The information collected in the military performance lab is ultimately used to help physicians, physical therapists, and prosthetists adjust their treatment plans and improve patient function.

OCTOBER 2015 | O&P ALMANAC

healing time to logistics. “Sometimes, it was weeks later,” he says. “Here, we’re able keep the continuity moving forward with no real downtime.” Because patients are usually only at the Center for a short time, Campbell says it’s imperative to treat them quickly, without unnecessary delays. Staff have mastered the art of the “hallway consult,” with therapists, surgeons, and clinicians meeting quickly to determine a more effective strategy and accelerate the course of treatment. “We’re not the only ones to do it, but we consider ourselves very effective at it,” Campbell says. This allows orthopedic surgeons, occupational and physical therapists, and technicians to work together—often putting a comprehensive plan in place within the first several days of a patient’s stay.

Occupational and Physical Therapy in Practice

Therapists, who offer a unique expertise to determine where the deficits are and strategies that might be helpful, are available to conduct detailed evaluations over the course of several

weeks—interacting with patients as they run, jump, and move—and then make immediate adjustments as necessary, says Wayne J. Strube, PT, DPT, staff physical therapist for CFI. Occupational therapy focuses on restoring health and function following injury or illness. At CFI, treatment strategies are created to allow patients to successfully perform functional tasks and activities of daily living (ADL) such as bathing, dressing, shopping, cooking, writing, and performing household chores on a day-to-day basis. The Center’s highly trained therapists and technicians provide evaluation and treatment, as well as recommendations and strategies for patients to regain range of motion, increase muscle strength, decrease pain, and facilitate their ability to perform functional tasks and to reach their maximum potential and independence. One hands-on example of ADL therapy is the ADL apartment. Simulating a typical home in an effort to provide patients with a realistic environment for practicing everyday skills, the apartment is furnished with a

PHOTOS: Courtesy of the U.S. Army

In the unique, circular building, CFI features clinical space, a military performance lab with a gait lab and computer-assisted rehabilitation environment, a pool, an indoor running track, a two-story climbing wall, and a prosthetic center. The space provides amputees and those with severe extremity injuries the unparalleled opportunity to regain their “highly active lifestyles” with comprehensive and exceptional care. In some cases, soldiers are able to return to active duty—a feat not easily possible before the construction of CFI. “One of the most unique things about CFI is that we have prosthetists, therapists, and clinicians working in the same spaces, everyday,” says Stuart M. Campbell, PT, MPT, program manager for CFI. “We’re a federal facility that is well-funded and well-staffed, so we are able to offer a well-rounded care program in an expedited manner.” Del Lipe, CPO, and CFI’s upperextremity prosthetics specialist, came from private practice, where a patient might have to halt all physical and occupational therapy to make adjustments, therefore losing valuable

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A patient uses the CAREN, a 21-foot dome with a 300-degree screen upon which a variety of “virtual realities” are displayed, to aid in his rehabilitation, while prosthetists and therapists observe for adjustments.

OCTOBER 2015 | O&P ALMANAC

running program as well as swimming, snow skiing, water skiing, track and field, basketball, volleyball, fencing, archery, shooting, golf, kayaking, and scuba diving activities.

State-of-the-Art Technology

CFI boasts a full-production prosthetic lab with eight technicians, and imminent plans for an expansion project in the lamination department of the facility. In addition, the Center recently adopted standing walk-in hours to further its mission of providing timely, high-quality care. CFI’s prosthetists and technicians work together to provide state-ofthe-art onsite fabrication of artificial limbs. Standard production methods are augmented by computer-assisted technology for design, milling, and production of prosthetic devices. The fabrication team can design unique specialty limbs for sports and other activities. In addition, the prosthetic lab offers wireless technology for remote adjustment of upper- and lower-extremity prostheses, as well as high-tech materials in combinations of acrylic resins, carbon fiber composites, and titanium.

CFI also houses a virtual reality system: the Computer-Assisted Rehabilitation Environment (CAREN). CAREN is a fully immersive virtual reality environment with a 21-foot dome and seven high-definition cameras projecting onto a 300-degree screen, with a treadmill, floor sensors, and body-con motion sensors. “CAREN gives us an environment where we not only get the data that we’d get in a traditional gait lab, but also in a distracted environment,” says Campbell. “We can see what the patient is doing and experiencing functionally—not just what they think we’re looking at.” While CAREN is not unique to CFI— there are 20 systems installed worldwide—CFI was the first in the state to use the technology, which is becoming increasingly popular in universities and hospital rehabilitation centers. In addition, the Military Performance Lab (MPL) seeks to analyze human motion, with particular emphasis on amputee gait. The information collected in the MPL is ultimately used to help physicians, physical therapists, and prosthetists adjust their treatment plans and improve patient function.

PHOTOS: Courtesy of the U.S. Army

computer workstation with voice recognition technologies, a fully equipped kitchen, laundry, bath, and living room. Patients are able to get real-world, integrated, and functional experience in a typical living situation, all while in the care of the experts at the Center. “We can run upstairs to the ADL training facility and sit and see, and devise a solution right away. And, because we fabricate everything, we can run downstairs to fix [the prosthesis], if needed,” says Lipe. In addition, CFI’s physical therapists are on hand to provide evaluation, diagnosis, treatment, and rehabilitation. For an amputee patient, for example, the therapy focuses on abilities and interests, not disabilities. “Total rehabilitation” at CFI means the physical therapy team provides amputation awareness and residual limb care for inpatients; wheelchair mobility and crutch training; strengthening activities; pre-prosthetic training working on dynamic balance, proprioception, and endurance; gait training on a variety of surfaces; and an adaptive sports program. The sports program allows patients to take part in a multiphased

PHOTO: Courtesy of the U.S. Army

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A patient utilizes CFI’s Firearms Training Simulator (FATS), a state-of-the-art system that simulates the firing of different weapons in a host of settings. Using the system, patients practice different firing techniques and may qualify with weapons systems common to the military.

The traditional gait lab allows technicians to calculate and analyze joint angles by using up to 24 cameras with infrared light to track the position of reflective markers placed on a patient’s body. Torque from muscles or prosthetic components can be identified through force plates in the floor, parallel bars, and treadmills, which measure ground-reaction forces in three directions. Meanwhile, the electromyography system can detect the timing and intensity of muscular contractions. This comprehensive monitoring allows prosthetists and therapists to best design a solution for patients to regain a comfortable, high-activity lifestyle in a timely manner.

CFI’s prosthetists and technicians utilize a team approach to provide state-of-the-art on-site fabrication of artificial limbs.

From the Center to Civilians

At CFI, which is classified as an “advanced rehabilitation center and research institute,” patients benefit from individualized case management, access to behavioral medicine services, and in-house prosthetic fitting and fabrication. Many of the innovations within CFI have resulted in studies that are then published in peer-reviewed journals, which benefit the civilian amputee population as well. CFI offers a clear research component within the facility, but product development does not take place at the Center. CFI has been integral to outcomes testing of many products in the O&P community. Among many examples of collaboration with manufacturers, CFI played a key role in the outcomes testing of the widely known BiOM T2 System—much of the early testing was done at CFI in the performance lab— having a significant impact within the community, says Fergason.

The Center of the Future

OCTOBER 2015 | O&P ALMANAC

Catherine Johnson is a contributing writer to O&P Almanac.

PHOTOS: Courtesy of the U.S. Army

To date, more than 23,000 service members have been wounded in operations in Afghanistan and Iraq. At the beginning of the conflicts, it was agreed that the medical community was not equipped to handle the degree of injuries that would likely result from the conflicts, and the Center was created after military personnel concluded that, “ …we were not prepared for [the serious injuries] we were about to see,” says Campbell.

“The Department of Defense made the commitment to develop a largerscale budget to respond to the injuries coming back [from the conflicts in Iraq and Afghanistan], and the complex cases we were beginning to see at that point,” says John Fergason, CPO, chief, prosthetics-orthotics at CFI. Prior to the creation of CFI, most amputees were being seen at Walter Reed Army Medical Center in Washington, D.C., says Fergason. According to the Intrepid Fallen Heroes Fund, which was responsible for raising $55 million for its construction, CFI is the “...ultimate joint venture between the American people and the armed forces.” Funded by donations from more than 600,000 Americans, the facility is now an integral part of BAMC, and the staff falls under the Department of Orthopaedics and Rehabilitation. Today, the Army funds CFI’s day-today operations. At the opening of the Center in the fall of 2007, President George W. Bush visited CFI for a behind-the-scenes tour. “The Center is a tribute to the generosity of the American people,” he said. “Make no mistake about it: The American people support the men and women who wear our nation’s uniform. The Center is a testament to our deep belief that someone wounded in defense of America needs all the help that he or she can get.” As CFI transitions to peacetime, staff have adopted the “Power Program,” which stands for Performance Optimization Warrior Enhanced Rehabilitation. Using the comprehensive model of CFI, and the rehab psychologies and strategies in place, the Center will add dietitians and sports nutritionists to work with therapists and prosthetists to develop and encourage total lifestyle support for patients. “We want to continue to create a comprehensive rehabilitation program for very injured individuals—to bring them to the highest level of functionality,” says Campbell.

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LEADERSHIP SERIES

DISSECTING

DISEASE TRENDS Understanding disease prevalence and forecasts can help O&P professionals adapt their practices

The O&P Almanac’s Leadership Series shares insights and opinions from senior-level O&P business owners and managers on topics of critical importance to the O&P profession. This month, we investigate the topic of disease trends.

Meet Our Contributors

S THE O&P PROFESSION begins to collect patient data to demonstrate the effectiveness of orthotic and prosthetic intervention in restoring function— data that is increasingly important to payors—it’s a good time for O&P practitioners to take a look at those disease trends that are emerging from data generated by other health-care sectors. Many medical disciplines already have a vast array of patient information—data that could prove useful to orthotists and prosthetists as they consider patient demographics and set business plans. With reimbursement challenges on the rise and profit margins on the decline, it has become more important than ever for O&P businesses to understand which types of patients may be in greatest need of services in the near- and long-term future. Those O&P business managers and clinicians who follow disease trends will be best positioned to treat the patients most likely to visit their offices in the coming years. Here, O&P experts share their thoughts on the importance of following disease trends, such as diabetes and cerebral palsy, and offer suggestions for staying current on relevant medical advances.

Thomas DiBello, CO, FAAOP, is clinic regional director at Hanger Clinic; honorary adjunct faculty at Texas Women’s University; and chairman of the Advisory Committee of the Baylor College of Medicine Masters Program on Orthotics and Prosthetics. He is past president of both AOPA and the Academy of Orthotists and Prosthetists.

OCTOBER 2015 | O&P ALMANAC

Phil Stevens, Med, CPO, FAAOP, is immediate past president of the American Academy of Orthotists and Prosthetists and is in clinical practice with Hanger Clinic in Salt Lake City, Utah.

Rudolf B. Becker is chairman and president of Becker Orthopedic, a supplier of orthopedic component parts and central fabrication services located in Troy, Michigan.

LEADERSHIP SERIES

O&P ALMANAC: Why should O&P professionals pay attention to disease trends? THOMAS DIBELLO, CO, FAAOP:

As we evolve as a profession, it’s important that we be very involved in understanding and appreciating the changes occurring in the diseases that we treat. For instance, if there were an effective way to completely cure diabetes, then there may be a diminished number of amputations for diabetes patients, and that would reduce the need for prosthetic devices for diabetic amputees. On the orthotics side, if physicians begin performing more prenatal intra-uterine surgeries to repair spinal insults that occur in unborn infants with spina bifida, and research shows that these patients are then more cognitively alert but still have neuromuscular limitations that require bracing, that may have an impact on orthotics treatments—and we would need to be aware that further advances could ultimately eliminate the need for those types of orthoses. One example of the importance of following disease trends can be seen in the case of a well-known rehabilitation hospital. During the course of a decade during the 1980s and ‘90s, the hospital transitioned from being primarily a spinal cord injury center to a hospital that primarily treats stroke patients. They were watching trends and recognized that the number of spinal cord patients was diminishing—mainly because the majority of spinal cord injuries occurred secondary to motor vehicle injuries. As cars became safer, there were fewer spinal cord injuries. A change in focus to stroke patients helped ensure the hospital’s longevity. We, as a profession, need to be equally aware of trends that may affect the work we do. PHIL STEVENS, MED, CPO, FAAOP:

Every industry has to forecast its future. Are the demands for their

services going to increase or decrease? For orthotics and prosthetics, disease trends constitute a big part of that forecasting. RUDOLF B. BECKER: It’s important to follow disease trends so the profession and the companies that supply practitioners can prepare for the future needs of patients and offer viable treatments to referral sources.

O&P ALMANAC: What do individual practitioners, or the O&P profession as a whole, need to do to ensure we follow disease trends? DIBELLO: I know there is a lot of

uncertainty in the profession these days related to possible Local Coverage Determination (LCD) changes and downward pressures on reimbursement, but we need to devote human and financial resources within the O&P profession to look at these trends, as so many other professions do. In the past, we have not studied the changes occurring in general medicine related to our patients whose diagnoses

we encounter the most. At times, we have been caught by surprise. We have to face this as a profession. We know very little about these areas of medicine we are most affected by, and we are at risk of being caught in a situation for which we are unprepared. STEVENS: I think individual practitio-

ners will continue to be dependent on larger entities within the profession to follow disease trends. Individual practitioners don’t have the time or means to access the kinds of data that tell those stories. However, organizations like AOPA and the Academy do. Journalists within the profession can also do so. Once these entities create secondary knowledge sources that summarize these trends, then it’s up to individual practitioners to consume them and include those findings in their decision making. BECKER: AOPA does a fine job of pub-

lishing data and the appropriate links in its biweekly AOPA in Advance Smart Brief and monthly O&P Almanac. They couldn’t be easier to access, and if you want more data, just use one of the search engines available online. O&P ALMANAC | OCTOBER 2015

LEADERSHIP SERIES

O&P ALMANAC: What are some of the current trends and developments we should recognize?

mandated. A similar change was seen decades ago when geneticists and genetic counselors came to a better understanding of the relative risks of Duchene’s muscular dystrophy.

DIBELLO: There is contradictory

BECKER: Cerebral palsy is the most common disability among children in the United States, affecting two to six infants out of every 1,000 births. The resulting balance and ambulation difficulties afford us a continuing opportunity to improve clinical applications and component design.

evidence that there is a reversal in the trend of increasing incidence of diabetes in America. There also is no indication that there has been a shift in the number of people with strokes, or with cerebral palsy. None of those trends is about to change. But we have to be aware that, given the kinds of advancements that are occurring, there could be changes, and they could happen rapidly. STEVENS: In recent years, the big one is diabetes. It’s pretty commonly understood that diabetes is on the rise nationally. It seems natural to extrapolate that observation to an expectation of increases in amputation secondary to diabetes and peripheral vascular disease. However, the numbers haven’t borne that out. Increased efforts in early screening and management have been such that amputation rates have actually gone down while the incidence of diabetes has gone up. BECKER: Our company is focused on orthotics, so one of the things we pay attention to is data on strokes. There are almost 800,000 strokes every year in the United States, and over 600,000 of these are first attacks. Therefore, we focus a lot of our research and development efforts on new methods of treatment for post-stroke rehabilitation.

O&P ALMANAC: Have there been any specific changes in the treatment of diabetes that orthotists and prosthetists should recognize? DIBELLO: The entire industry has

evolved. Limb salvage techniques have never effectively been shown to have a better impact on mobility or a better quality of life than amputation. There is a current initiative to talk about “gait salvage” rather than “limb salvage.”

OCTOBER 2015 | O&P ALMANAC

I would recommend that every interested party visit the excellent Mobility Saves website at mobilitysaves.org that AOPA has developed over the last few years. O&P professionals need to help develop evidence to present to the individuals who perform limb salvage surgeries that, in the long run, amputation may be a better answer—surgeons need to consider the bigger picture. STEVENS: Early screening and preven-

tion programs have had an impact. Patients with milder diabetes appear to be less likely to go on to amputation. Those with more aggressive diabetes are still requiring amputation. As a result, the [diabetic] amputee who comes to your office now probably has, on average, worse overall health than [the diabetic amputees] you saw 10 years ago. O&P ALMANAC: Are there any trends in pediatric care we should be following?

STEVENS: There are certainly examples

of past trends. The impact of folic acid fortification in breakfast cereals had a very real impact on the incidence of spina bifida, for example. You can look at those numbers and watch them fall as folic acid fortification was an optional suggestion and later

O&P ALMANAC: Once we recognize a new trend, what can we do to stay up-to-date on new information? DIBELLO: If we see something evolv-

ing, we may want to develop alliances with related organizations, such as nonprofit associations or information repositories related to those areas of medicine. It also would make sense for us to fund a database with information related to our patients with conditions such as diabetes, stroke, cerebral palsy, and things of that nature, which would allow us to observe trends in these areas. Then we could know, with a higher degree of certainty, what we need to anticipate. STEVENS: Forecasting is still forecast-

ing. Financial planners can give you a very detailed analysis of what happened to the market so far this year. When you ask them what will happen next year, the stories start to change. In general, we are a lot better at knowing what just happened then we are at knowing what’s around the corner. BECKER: From the perspective of a manufacturer, it’s important to not just look at the data, but to spend even more time talking to the practitioners in the field that see firsthand what’s needed. From there, we can attempt to design a solution that helps the practitioners, and ultimately the patients we all serve.

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COMPLIANCE CORNER

By DEVON BERNARD

Gifting Guidelines The Stark Law and the Anti-Kickback Statute serve as guidance when offering gifts and discounts By DEVON BERNARD

Editor’s Note: Readers of Compliance Corner are now eligible to earn two CE credits. After reading this column, simply scan the QR code or use the link on page 56 to take the Compliance Corner quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.

CREDITS

HEN DISCUSSING GIFTS OR discounts intended for referral sources

or patients, the conversation will eventually lead to the Stark Law and the Anti-Kickback Statute. The two rules often are confused for each other or used interchangeably because they both have the intent to control financial incentives that may influence the outcomes or type of treatment a patient may receive. However, the two laws are different in their scope, structure, and approach in curtailing financial incentives. This month’s Compliance Corner provides a quick comparison of the two regulations and explains what is allowed, what is not allowed, and the difference between restrictions on gifts and discounts for patients and referral sources. It’s important to make sure gifts and discounts are not misconstrued as inducements, and that they don’t inadvertently violate laws or regulations.

The Stark Law Versus the Anti-Kickback Statute

E! QU IZ M EARN

BUSINESS CE

CREDITS P.56

OCTOBER 2015 | O&P ALMANAC

The Stark Law was introduced in 1989, with the intent to halt or end the practice of self-referrals. The 1989 version of the law dealt only with physicians’ referrals to clinical labs; however, it was later revised to expand the list of services, called “designated health services,” to include nine additional types of care—including orthotic and prosthetic services. Specifically, the Stark Law is a civil statute that: 1. Prohibits physicians from making referrals for clinical laboratories or other designated health services (e.g., orthotics and prosthetics) to entities in which the physician has an ownership or financial interest. 2. Prohibits entities from presenting or causing to be presented [with] claims or bills to any individual, third-party payor, or other entity for designated health services (e.g., orthotics and prosthetics) furnished pursuant to a prohibited referral.

In a nutshell, physicians may not refer patients to an outside business with which they or their family members have a direct financial relationship. The punishment for violating the Stark Law may range from civil monetary penalties of $15,000 for each violation (referral) to exclusion from federally funded programs. On the flip side, the Anti-Kickback Statute, which was originally enacted in 1972 and has been modified and amended over the years, is a criminal statute that “prohibits the knowing and willful offer, payment, solicitation, or receipt of remuneration to induce federal health-care program business.” In plain English, it is illegal to provide anything of value or perceived value, regardless of the monetary value, if the intent is to receive referrals of patients who are enrolled in governmentfunded health-care programs. The penalties for violating the Anti-Kickback Statute are a little more severe than for the Stark Law, and

COMPLIANCE CORNER

For More Information

In addition to the directives discussed in this Compliance Corner article, AOPA has published its own document regarding the provision of gifts to referral sources. The 2009 document is based on guidance originally published by the Pharmaceutical Research and Manufacturers of America and is a valuable resource in determining how to offer gifts of minimal value to referral sources without running afoul of federal Anti-Kickback statutes. The American Orthotic and Prosthetic Association Code of Interaction With Health-Care Professionals is available on AOPA’s website, www.aopanet.org/ about-aopa/privacy-policy. This document is not legally binding but is to be used as a guideline, and it is intentionally stricter than the directives found in the Stark Law and the Anti-Kickback provisions. may involve both a criminal and a civil penalty. On the criminal side, a violation of the Anti-Kickback Statute could lead to up to a five-year prison sentence and up to a $25,000 fine per violation. On the civil side, violators could experience expulsion from federally funded programs and up to $50,000 in fines per violation of the statute.

Gifts to Referral Sources

When considering offering a gift to a referral source and/or its office staff, remember that gifts of cash or cash equivalents of any kind are prohibited. Cash equivalents include items such as gift certificates, gift cards, and even free samples of products. If cash and cash equivalents are not an option, what types of gifts are acceptable? Nonmonetary gifts are allowed. However, there is a limit to the amount, or aggregate total, of nonmonetary gifts that is acceptable. This limit is increased annually to reflect inflation and is adjusted according to the increase in the Consumer Pricing Index. The aggregate limit for 2015 is $392— and this is a limit, not an entitlement. In addition to the value limit on nonmonetary gifts to referral sources, several other restrictions govern the provision of gifts. First, the value of the gift may not be tied to the volume of referrals received from a physician’s office. For example, you cannot provide a gift of 54

OCTOBER 2015 | O&P ALMANAC

higher value to your regular referral sources than you do to practices that only refer patients periodically. While you are not required to offer the same gift to all of your referral sources, you cannot base your decision on the number of referrals you receive. Second, gifts may not be solicited by referral sources. If a physician’s office requests a specific gift and you provide it, the Office of the Inspector General (OIG) considers it an inducement in the hope of receiving future referrals and classifies it as a violation.

Gifts to Medicare Patients

The Social Security Act (Section 1128 A(a)(5)) states: “A person who offers or transfers to a Medicare/Medicaid beneficiary any renumeration that the person knows or should know is likely to influence the beneficiary’s selection of a particular supplier of Medicare/Medicaid payable items or services may be liable for civil money penalties.” This statement might be construed as disallowing any gifts to patients. However, gift giving is allowed, with several restrictions. In August 2002, OIG published a special fraud alert that set guidelines on gifts that providers may offer to Medicare beneficiaries; these guidelines are still active today. Three main rules must be followed: 1. Gifts cannot be cash or eligible for cash equivalents. Gifts of

cash or cash equivalents of any kind are strictly prohibited. 2. Gifts must be “inexpensive.” The value of gifts to beneficiaries should not exceed $10 per gift or $50 aggregate per calendar year, which means you may offer a Medicare beneficiary a maximum of five gifts valued at $10 in any calendar year. 3. You may not give a gift with the intent of “securing your services to a patient.” For example, you cannot require that a patient come in for an evaluation in order to receive a gift, or mandate that a patient may receive a gift only if he or she chooses to receive a particular service or item.

Patient Discounts

Providing a discount to a patient is much trickier than providing a gift. Several types of discounts have received safe harbor status or have been approved by CMS and/or OIG; here, we will focus on the two that O&P providers are most likely to use. The first acceptable discount is a waiver of coinsurance and deductibles. You are permitted to waive coinsurances and deductibles, but only in cases where a patient is financially unable to pay. If this scenario exists, providers may make a case-by-case decision to waive a patient’s coinsurance and/or deductible. This decision should be well documented in your records. While it is not a requirement to take extreme measures to document a patient’s overall financial status (e.g., tax returns, pay stubs, etc.), you should document that you have reason to believe that the patient cannot afford his or her deductible or coinsurance and that you have made an individual decision to waive his or her financial responsibility. The method you use to determine a patient’s financial status should be consistent and be followed evenly for all patients and by all billers/practitioners. The second acceptable discount is a cash-pay or prompt-pay discount, or the discount you may offer if a patient is paying cash at the time of service or within an established timeframe.

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COMPLIANCE CORNER

When considering providing a cash-pay discount, you will need to take into consideration five requirements that are based on an OIG advisory opinion for a health-care system’s prompt-pay program. (Note that the results of an advisory opinion are specific to the entity requesting the opinion, but the opinion may be used as a guidepost.) The first and second requirements for cash-pay discounts go hand and hand. The discount program may not be advertised, and the only time patients may be informed of the discount is through the ordinary billing process. In other words, the availability of the discount should not be an inducement to a patient to choose your facility or your services over a competitor; rather, the discount eases the administrative burden (no need to bill or go through the collection process). The third requirement is that all third-party payors must be aware of the discount, and the discount must apply and be available to all payors—not just Medicare patients.

OCTOBER 2015 | O&P ALMANAC

Under the fourth requirement, any costs associated with providing the discount must be absorbed by the health system (supplier/provider). In other words, you may not charge other patients more to make up the difference in the discount. With the fifth requirement, the discount must have a reasonable relationship to the amount saved by the health system (provider/ supplier), or what should be a justifiable discount. The advisory opinion mentioned that discounts in the 5 to 15 percent range would be considered reasonable, and that these discounts should be applied to the allowable amount and not the “retail amount.” Also, as with a financial hardshipwaived copay discount, a cash-pay discount should have clearly set parameters establishing when and how the discount is given. Be sure to have a strong written policy in place that outlines your company’s gift-giving and discount protocols. When dealing with discounts

and gifts for your patients and referral sources, consider consulting with an attorney, as it can be very easy to slip over the line from compliance to noncompliance. You also may request that the OIG render an advisory opinion on your particular arrangement or gift-giving plan, but this service is not free. For information on OIG advisory opinions, visit the OIG website. 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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MEMBER SPOTLIGHT

Turbomed Orthotics

By DEBORAH CONN

Startup Story Canadian inventors develop outside-the-shoe AFO for foot drop

IKE SO MANY INVENTIONS,

the FS-3000 ankle-foot orthosis (AFO) came about because its inventor, François Côté, needed something that didn’t yet exist. Côté had been left with foot drop and lack of sensation in his left foot after a snowmobile accident in 2001. He was an avid runner, but the AFO he was wearing wasn’t up to the task. After completing a marathon about seven years ago, Côté realized he could actually see his ankle bone, his skin shredded by the device. Côté decided he could no longer run with an AFO inside his shoe, so he set about designing an alternative.

COMPANY: Turbomed Orthotics LOCATION: Quebec City, Quebec

OCTOBER 2015 | O&P ALMANAC

OWNERS: François Côté and Stephane Savard HISTORY: Four years

PHOTOS: Turbomed Orthotics

The FS-3000 foot-drop orthosis was the result. Côté and long-time orthotist and business owner Stephane Savard formed Turbomed Orthotics and spent years developing and refining the device. The FS-3000 (its initials signifying François and Stephane) is designed to be worn outside the shoe and controls motion of the foot during dorsiflexion and plantarflexion. It is made of thermoformable plastic, which is unbreakable, says Savard, unlike carbon fiber. “We can heat it to add more dorsiflexion or change its shape, and it offers the same energy return of any carbon fiber device because of its design.”

The stiffness of the device gives added support and provides lateral stability on uneven surfaces. But it makes no contact with the plantar face of the foot or ankle so it eliminates friction injuries. Turbomed promotes use of the AFO for sports and other vigorous activities, and Côté has worn it running, hiking, and snowshoeing. One customer uses it for ice climbing. The device adjusts so it can be moved from one shoe or boot to another in about 20 seconds, says Savard. Côté and Savard first publicized their invention by making a YouTube video. “We sold our first brace to a man in Israel, the second to someone in Florida,” says Savard. Turbomed developed a website where customers can contact the company and order via email. True to startup myth, Turbomed is still housed in Savard’s garage, although the inventors have expanded to the neighbor’s garage as well. (Inventory moves into an actual warehouse October 1.) Côté and

Savard, the only two employees at Turbomed, are producing about 20 braces a week for direct sale, without any serious marketing efforts, and they plan to introduce the FS-3000 to the U.S. orthotist market this month at the AOPA National Assembly in San Antonio. The company developed a kit to help orthotists determine the correct size of the device. “When you order a custom-fit knee brace, they will use a tool to measure the leg. But you don’t know how the brace will feel,” Savard explains. “Our measuring tool is the brace itself, with a few components that are adjustable. So the orthotist can adjust the device to obtain the correct size, and the patient can know immediately how it feels and if it will help.” The FS-3000 can fit women’s size 7 to men’s size 16 shoes, and Turbomed is developing a smaller version for children and smaller women’s sizes. The company has applied for FDA approval and hopes to have an L code before long. Savard says that some large O&P suppliers have expressed interest in the FS-3000, and it may be that another company will snatch it up. “We thought we invented a brace,” says Savard. “But instead we invented a new way to make AFOs for patients with foot drop. And that’s why people are so interested in our product.” Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net.

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MEMBER SPOTLIGHT

UT Medicine O&P Clinic at the University of Texas Health Science Center

O&P Amid Academia San Antonio clinic sees wide variety of patients in research-friendly setting

OR JESSE RETTELE, L/CPO,

OCTOBER 2015 | O&P ALMANAC

FACILITY: UT Medicine O&P Clinic at the University of Texas Health Science Center OWNER: University of Texas Health Science Center LOCATION: San Antonio, Texas HISTORY: 36 years

Jesse Rettele, L/CPO

and rehabilitation residency, research, and clinical programs. Four technicians and a lab supervisor fabricate all of the orthotic and prosthetic devices in the O&P lab attached to the UT Medicine clinic location. The UT Medicine clinic and the clinic downtown at TDI each contain three patient treatment rooms, with parallel bars and mirrors, and a fabrication lab. The clinic does all fabrication in house and relies heavily on computeraided design fabrication. “We are the face mask experts in town,” says Rettele. “All the sports teams end up here. We can scan the patient and fabricate a polycarbonate face mask in approximately three business days.” CAD/CAM is especially useful for acute trauma cases. Patients with head injuries often have bone removed to allow the brain to swell. Using a scanner to measure the head for a protective helmet is fast and noninvasive. Being part of an academic institution also allows staff practitioners to serve a diverse patient population, with exposure to educational and research opportunities for other subsets of clinical care, says Rettele. “If we are not covered by a patient’s insurance or authorized to dispense a particular device, we refer patients to other local providers. But we rarely turn a patient away for lack of funding because there are options available,” he says. “Our program embraces technology and we utilize the most appropriate devices and interventions despite the challenging reimbursements from insurance companies. We collaborate with other academic O&P facilities to provide a comprehensive approach in patient care.” Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net.

PHOTOS: UT Medicine O&P Clinic at the University of Texas Health Science Center

working at an O&P clinic at a major university is quite a bit different from his experience in a privately owned facility. “I didn’t engage in research and wasn’t involved in education,” at the independent facility, says Rettele, who is medical director for O&P services at the University of Texas (UT) Medicine O&P clinic. “There wasn’t volume for after-hours calls, and I rarely saw immediate trauma or rare neurologic conditions like Charcot Marie Tooth or ALS [amyotrophic lateral sclerosis].” The O&P clinic where Rettele has worked since 2005 is part of the Department of Rehabilitation Medicine within the School of Medicine at the UT Health Science Center in San Antonio, a state institution. The department offers a four-year residency program for physical medicine and rehabilitation physicians, and residents rotate through the O&P clinic on a monthly basis. In addition, O&P providers present a series of lectures in orthotics and prosthetics during the four-year physiatry residency program. The two clinics are located at the medical school and at a satellite location inside the Texas Diabetic Institute (TDI). TDI is a comprehensive center operated by the university health system, and the O&P clinic also provides inpatient and emergency services at its hospital facility. “We cover inpatient and outpatient care for patients in the health system and work with a number of departments, including trauma, orthopedics, neurosurgery,

neurology, and vascular surgery,” explains Rettele. “Physicians refer patients to us, and we often collaborate on care.” A major benefit to working so closely with the health system is early involvement in amputation cases. “Orthopedics does a great job of incorporating us into the process before an amputation occurs,” says Rettele. “We bring the patients samples of prostheses, peer support literature, and patient advocates.” For appropriate candidates, clinicians are able to fit patients with immediate postoperative prostheses right in the operating room. This strategy expedites recovery time and helps reduce or eliminate phantom pain, says Rettele. He notes that only a few trauma centers offer this option, which must be carefully managed in a controlled rehabilitation environment. O&P providers work closely with physical therapists and various physicians in the UT Health Science Center as well as the University Hospital System, both in determining the appropriate device and justifying medical necessity with evidence-based outcomes. The department employs two certified prosthetist/orthotists, a certified pedorthist, four clinical staff members, and a clinical supervisor, “who manages the clinical staff and assists in the paperwork nightmare,” says Rettele. As medical director, he works with the department administrator who manages the department’s operations, including the physical medicine

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AOPA NEWS

Join the Coding Experts in Las Vegas November 9-10

Understanding the LSO/TLSO Policy Register for the October 14 Webinar Are you curious about what type of documentation is required when providing a lumbosacral orthosis (LSO) or thoracolumbosacral orthosis (TLSO)? Have you ever accidentally billed the wrong payor when providing an LSO or TLSO, and wondered why? Learn the answers to these questions and many more by attending the October 14 webinar: “Understanding the LSO/TLSO Policy.” Topics for discussion will include the following: • When to bill the hospital for an LSO/ TLSO, and when to bill Medicare • The difference between custom-fabricated, custom-fit, off-the-shelf, and prefabricated LSOs and TLSOs • Criteria that must be met to provide an LSO/TLSO • A general review of the Local Coverage Determination and Policy Article. 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 Ryan Gleeson at rgleeson@AOPAnet.org or 571/431-0876 with questions.

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. Join your colleagues November 9-10 in Las Vegas.

Top 10 Reasons To Go to Vegas: 1. Get your claims paid. 2. Increase your company’s bottom line. 3. Stay up to date on Medicare billing. 4. Code complex devices. 5. Earn 14 CE credits. 6. Learn about audit updates.

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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.

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OCTOBER 2015 | O&P ALMANAC

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AOPA NEWS

CODING CORNER

ICD-10 Conversion Tool Now Available The Oct. 1, 2015, deadline is here! The nation has transitioned from Version 9 of the International Classification of Diseases (ICD-9) to ICD-10 coding for medical diagnoses and inpatient hospital procedures. AOPA has partnered with the Coding Institute to provide an ICD-10 conversion tool to all members. This free membership benefit allows you to quickly find a corresponding ICD-10 code simply by typing in any ICD-9 code. Access the conversion tool at bit.ly/icdbridge. To learn more about the changes and gain a general understanding of the impact the transition will have on O&P providers, read the Reimbursement Page article in the June 2015 issue of the O&P Almanac. This article, written by AOPA Director of Coding and Reimbursement Services, Education, and Programming Joe McTernan, is available from the O&P bookshelf: www.aopanet.org/publications/digital-edition. Read the article directly at bit.ly/icdstory.

Have You Read the O&P Almanac’s Leadership Series? Find out what senior-level O&P professionals have to say about the most critical issues facing the O&P profession. Several 2015 issues of the O&P Almanac have featured a new Leadership Series, showcasing Q&As with O&P experts on targeted topics of importance to the profession. Visit www.aopanet.org/publications/digital-edition to access past issues of the magazine and read what executives have shared, in their own words, on these important topics: TURF WARS Rick Riley; Cindy Henderson, BOCO; Charles Kuffel, MSM, CPO, FAAOP; and Tom Padilla, CPO, give their opinions. March 2015 O&P Almanac, page 34 FINDING YOUR NICHE Jonathan Naft, CPO; Megan McCarthy, CO; Dennis Clark, CPO; and Jon Bengtsson offer up their experiences. April 2015 O&P Almanac, page 36 HOSPITALS— WHAT’S THE HYPE? Andrew Meyers, CPO; Jim Kingsley; and Rebecca Hast detail their success strategies. June 2015 O&P Almanac, page 34

Coding Questions Answered 24/7 AOPA members can take advantage of a “click-ofthe-mouse” solution available at LCodeSearch.com. AOPA supplier members provide coding information about specific products. You can search for appropriate products three ways—by L code, by manufacturer, or by category. It’s the 21st century way to get quick answers to many of your coding questions. Access the coding website today by visiting www.LCodeSearch.com. AOPA’s expert staff continues to be available for all coding and reimbursement questions. Contact Devon Bernard at dbernard@AOPAnet.org or 571/431-0854 with content questions.

OCTOBER 2015 | O&P ALMANAC

TECHNOLOGY SMARTS David Boone, PhD, MPH; Jan Saunders, CPO; and Stephen Blatchford share their insights. July 2015 O&P Almanac, page 36 A PLACE IN THE CONSOLIDATION CONTINUUM Pam Filippis Lupo, CO/LO; Mike Sotak; and Rick Riley weigh in. September 2015 O&P Almanac, page 36

LEADERSHIP SERIES

O&P ALMANAC: What is the difference between consolidation and vertical integration?

A Place in the

CONSOLIDATION Continuum?

Experts weigh in on the future of independent O&P facilities amid evolving economics

Meet Our Contributors

Pam Filippis Lupo, CO/LO, is a member of the board of directors at Wright & Filippis and at Carolina O&P. She also is a surveyor for the facility accreditation program of the American Board for Certification in Orthotics, Prosthetics, and Pedorthics, and an industry consultant.

38 SEPTEMBER 2015 | O&P ALMANAC

S O&P PROFESSIONALS GRAPPLE with reimbursement challenges and dwindling profit margins, it’s impossible to ignore the industry consolidation trends taking place within the greater health-care arena. The number of “independent” health-care providers across medical specialties is falling. In fact, the number of U.S. physicians in independent practice has dropped significantly, from 57 percent in 2000 down to 37 percent in 2013, with a predicted decline to 33 percent by the end of 2016, according to data published by Accenture. The same report finds that those independent physicians who have sold their practices or sought employment directly with health systems have done so largely due to disruptive market conditions, such as reimbursement pressures. Some of the independent physicians who have kept their practices are coping by experimenting with other models to remain competitive—for example, 17 percent of U.S. independent physicians are participating in accountable care organizations (ACOs). Today’s O&P practitioners are facing similar reimbursement challenges and increasing costs. Several independent O&P facilities have recently consolidated with larger O&P practices, or have aligned themselves with suppliers or distributors on the O&P production pathway. What do these consolidation and vertical integration trends mean for today’s typical O&P provider and the outlook for the O&P profession? O&P Almanac recently spoke with three O&P experts, who shared their insights on the current business climate and the pros and cons of industry consolidation.

Mike Sotak is president and chief executive officer of PEL in Cleveland, Ohio. Sotak acquired PEL two years ago, after a diverse business career managing distribution and manufacturing businesses in pharmaceuticals, wound care, durable medical equipment, and related health fields.

Rick Riley is chief executive officer of Townsend Design in Bakersfield, California, a company with more than 150 employees. He worked in hospital administration before joining Townsend in 1995 as vice president of marketing, then took on duties as the company’s vice president of sales and marketing in 1997. He assumed the role of CEO in 2003.

PAM FILIPPIS LUPO, CO/LO:

Consolidation is a merger or acquisition of smaller companies into a larger company. Vertical integration is when the supply chain or manufacturer owns the company to which it supplies products. MIKE SOTAK: Consolidation is gener-

ally driven by the need or objective to realize economies of scale; it’s fewer companies getting bigger to leverage costs and gain efficiencies. With vertical integration, the goal is usually different—diversification, to spread risk, or to gain control upstream or downstream across the continuum of care. Examples of vertical integration include aligning with referral sources and partnering with physical therapists or other service providers, such as ACOs. Many O&P facilities right now are vertically integrated with c-fabs, which are technically custom manufacturing operations.

O&P ALMANAC: What types of

consolidation and/or vertical integration are occurring in O&P right now?

LUPO: There are a number of differ-

ent ways O&P facilities are consolidating and being integrated into larger companies. For example, O&P companies are buying other O&P companies. Several O&P companies have made acquisitions, including Hanger, Wright & Filippis, Level Four O&P, and New England Orthotics and Prosthetics. Some O&P companies are combining with physical therapy. Some hospitals are buying O&P and durable medical equipment (DME) facilities. Some physician groups are acquiring prosthetists. On the manufacturing side, some manufacturers are working together,

or are working together with O&P as a provider, potentially under competitive bidding. There are numerous configurations. SOTAK: We’re seeing some consolidation on the patient-care side. Some larger regional players are looking to acquire other practices—facilities that are looking to get bigger for efficiencies of scale. For example, many organizations are feeling a need to hire compliance officers—but how can you afford to hire someone on staff as a compliance officer if you’re a two-person staff? So they’re looking to consolidate to justify hiring professionals necessary to consistently meet regulatory requirements. We’re also seeing consolidation at the manufacturer level, and I think we will see a lot more as manufacturers face new challenges in meeting expected financial performance. RICK RILEY: There is an emerging

model, especially in larger markets, where hospitals, physician clinics, and ancillary services—including

O&P—are vertically integrated to create increased synergy and efficiency. In some cases, a local O&P facility is purchased by a large medical provider, and in other cases the network is hiring in-house orthotists and prosthetists. Among suppliers and manufacturers, there is also increasing consolidation. The companies that have the financial capital to make acquisitions can amass a vast range of products. This creates a strategic advantage in terms of offering one-stop-shopping to group purchasing organizations and integrated provider networks. O&P ALMANAC: What types of opportunities do these mergers present for the O&P profession and its patients? LUPO: Mergers and acquisitions can

lead to decreased costs due to the consolidation of redundancies. They may also allow O&P companies to expand into different scopes of practice—for example, foot care or DME. O&P ALMANAC | SEPTEMBER 2015

ZERO CLEARANCE! Controls Rotation

PROXIMAL LOCK CD116 | Proximal Lock Patent No. 6666894, 7431738, 7077868. Other patents pending.

ZERO CLEARANCE lock Controls rotation Use with your choice of distal adapters Larger attachment distributes more tension; rolls on easier Strip now added for reinforcement and less friction Simply easier. Designed to control rotation and be more user-friendly, the Proximal Lock attaches over a larger area, which distributes weight more evenly. The adhesive included with each lock is flexible even after it sets, making donning simpler.

See online video explaining the simplicity of patient socket adjustment at coyotedesign.com

Phone (208) 429-0026 www.coyotedesign.com

AOPA NEWS

Stay in the Know— Subscribe to AOPA’s Take! AOPA has designed AOPA’s Take, a new blog to keep you informed about important issues and up-to-date with 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!

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 member of AOPA if, within 30 days of publiwww.AOPAnet.org cation, no objections are made regarding the company’s ability to meet the qualifications and requirements of membership. At the end of each new facility listing is the name of the certified or state-licensed practitioner who qualifies that patient-care facility for membership according to AOPA’s bylaws. Affiliate members do not require a certified or state-licensed practitioner to be eligible for membership. At the end of each new supplier member listing is the supplier level associated with that company. Supplier levels are based on annual gross sales volume.

Blue Sky Orthotics & Prosthetics 2611 E. 29th Street Bryan, TX 77802 979/704-6309 Category: Patient-Care Facility Aaron E. Foreman, CPO, MSPT

Cobb Prosthetics 833 Weber Road Farmington, MO 63640 573/760-0520 Category: Patient-Care Facility Matthew D. Cobb, CPO

Is Your Facility Celebrating a Special Milestone? 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.

OCTOBER 2015 | O&P ALMANAC

Diablo Prosthetics & Orthotics 4479 Stone Ridge Drive, Ste. A Pleasanton, CA 94588 925/484-6400 Category: Patient-Care Facility Kathleen Pelz, CO G and G Prosthetic Services 2211 S. 57th Street Temple, TX 76504 254/771-5002 Category: Patient-Care Facility Jesse Goss, CPO Mid-Atlantic Prosthetics & Orthotics 1451 Bellehaven Road Alexandria, VA 22307 202/842-8425 Category: Patient-Care Facility Ron Longo, CP, COA New Life Brace & Limb 250 Blossom Street, Ste. 200 Webster, TX 77598 281/316-5805 Category: Patient-Care Facility Robert Draeger, CPO, LPO, CPed

Premier Hope Orthotic & Prosthetic Enterprises LLC 1209 Royal Avenue Monroe, LA 71201 318/812-0119 Category: Patient-Care Facility Steve Lindsley, CP, BOCO Xi’an Boao Prosthetic & Orthotic Company Ltd. 17 W. South Second Loop Road, 4th Floor Xi’an 710068 China 800/840-9270 Category: International Qingcheng Tang

949/645-4401 ● 800/854-3479 ● www.kingsleymfg.com

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*:

• • • • • • •

Kel Bergmann, CPO Don DeBolt Rick Fleetwood, MPA Jeff Lutz, CPO Walter Racette, CPO Scott Schneider Frank Vero, CPO

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 Charles H. Dankmeyer Jr., CPO, and who support the orthotic and Senator Chuck Grassley (R-Iowa) at prosthetic community. the AOPA 2015 Policy Forum 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.

We cordially invite you to attend the:

& During the 2015 AOPA National Assembly Thursday, October 8 6:30-8:00 PM The Henry B. Gonzalez Convention Center Room 001B (Convention Center River Level)

San Antonio

This is a special event and will require a separate registration fee. For additional information about the Wine Tasting & Auction or to register, contact Devon Benard at DBernard@AOPAnet.org.

OCTOBER 2015 | O&P ALMANAC

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: • Frank Bostock, CO • James Campbell, PhD, CO • Maynard Carkhuff • Jeff Collins, CPA • Thomas Costin • Charles Dankmeyer Jr., CPO • Kathy Edwards, Cfm • David Edwards, CPO, FAAOP • Thomas Fise, JD • Rick Fleetwood, MPA • Al Kritter, CPO, FAAOP • Eileen Levis • Anita LibermanLampear, MA • Pam Filippis Lupo, CO/LO • Jeff Lutz, CPO • Sara Lutz • Joe Martin, COO • Dave McGill • Tina Moran, CMP • Chris Nolan • Michael Oros, CPO, FAAOP • Scott Schneider • Mike Sotak • Donald Shurr, CP, PT • Jim Weber, MBA • Steve Whiteside, CO *Due to publishing deadlines this list was created on Aug. 31, 2015, and includes only donations/ contributions made or received between April 1, 2015, and Aug. 31, 2015. Any donations/ contributions made or received on or after Aug. 31, 2015, will be published in the next issue of the O&P Almanac.

DOWNLOAD the 2015 National Assembly App • Get up-to-date information regarding the National Assembly • Easily view the agenda and set up your own personal schedule • Interact with colleagues • Share photos and comments • Search for speakers and specific topics • Navigate the exhibit hall • Review speaker bios

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

…and that’s not all: • Learn About AOPA • Review the O&P Almanac • See how membership with AOPA has its benefits • Get current with Hot Issues • See how Mobility Saves • Visit the AOPA Bookstore • Access the AOPA Membership Directory • Connect with AOPA through social media

REGISTER ONLINE: bit.ly/aopa2015 GENERAL INFORMATION: bit.ly/aopashow HOTEL RESERVATIONS: bit.ly/assemblyhotel QUESTIONS: Visit www.AOPAnet.org or contact AOPA at 571/431-0876 or info@AOPAnet.org.

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.

XRD Is Now Available From Acor! BOOTH #718 XRD stands for Extreme Impact Protection. It is lightweight material that is engineered to absorb up to 90 percent of energy when impacted under high strain rates. This product is infused with an antimicrobial protectant, which will help prevent the growth of bacteria that can cause stains and odors. Under the foot, the foam’s memory-like properties provide a contoured fit for each user. XRD raises the bar when it comes to comfort, control, and protection. Call today for your free sample! For more information contact Acor Orthopaedic Inc. at 800/237-2267, ext. 1, or visit www.acor.com.

MultiMotion From Allard USA BOOTH #537 This dynamic corrective system joint ensures fast, efficient, and effective treatment of contractures resulting from neurological conditions. Simple and Uncomplicated • Just two joint sizes, Small and Regular, accommodate any extremity joint of the body. • No complicated order forms to complete—you determine and control all adjustments. Just Three Simple Adjustments 1. Flexion/Extension: Just flip the joint housing internal spring based on anatomical location. 2. ROM: Limit range of motion in 12-degree increments for size Small and 14 measurements for size Regular. 3. Force Control: Up to 3.4 NM (30 in-lb) for size Small and up to 10.2 Nm (90 in-lb) for size Regular. Visit www.allardusa.com and click on MultiMotion for more information, call 888/678-6548, or email info@allardusa.com.

OCTOBER 2015 | O&P ALMANAC

ALPS Thinner Seamless Suspension Sleeve BOOTH #501 Formulated with the ALPS GripGel, the new SFB seamless suspension sleeve provides superior comfort with a single-piece construction. The SFB sleeve features a new black-knitted fabric that allows the user excellent freedom of knee flexion. This new sleeve seals with the skin without restricting circulation, while the GripGel sticks to the patient’s skin without causing shear forces. With a thinner profile of 2 mm, the SFB is an ideal choice for those concerned about bulk. For more information, contact ALPS at 800/574-5426 or visit www.easyliner.com. ALPS is located at 2895 42nd Ave., North St. Petersburg, FL 33714.

It’s Your Patient; Shouldn’t It Be Your Orthotic Design Too? BOOTH #233 Take complete control for the ultimate in patient satisfaction with Amfit Lab Services. • Carbon fiber (flex and firm) • Polypropylene (flex, semi-flex, rigid) • Five EVA styles and densities • One- to four-day turnaround • Diabetic specific program: three pair for $60, includes shipping • Foam box processing • Contact Digitizer 3D Digital Casting system • Equipment rental and lease programs available Thirty years specializing in custom foot orthotics and orthotic technology, we will help move your practice forward while saving time and money. Contact Amfit Inc. today at 800/356-FOOT(3668), email sales@amfit.com, or visit www.amfit.com.

MARKETPLACE Introducing the Triple Action™ Stance/Swing Control Ankle Joint BOOTH #325 The Triple Action™ Stance/Swing Control ankle joint provides: • Independent adjustment features that correspond to the phases of the gait cycle • Simplification and optimization of alignment and range-of-motion • Independent alignment adjustment of the sagittal plane ankle angle of ± 10°. For more information on the Triple Action™ Stance/ Swing Control ankle joint, please visit our website at BeckerOrthopedic.com, or contact one of our customer service representatives today at Becker Orthopedic at 800/521-2192.

Introducing the OdysseyK2 Hydraulic Foot from College Park BOOTH #431 Hydraulic feet can provide K2 patients with an incredible range of controlled motion as well as assist in force absorption, enhance knee stability and promote good posture. It also gives the patient the ability to maintain foot flat with a fluid transition from sit to stand, for a comfortable, natural look. The new OdysseyK2 foot from College Park has a patented curved hydraulic ankle, Intelliweave™ composite foot base, and customizable dual StrideControl™. This revolutionary foot provides a superior range of motion in a lightweight and low profile design for an unbeatable combination of K2 patient benefits. See it in action at youtube.com/CollegeParkInd. For more information, visit College Park Industries at www.college-park.com.

Coyote Design: Composite Braid

BOOTH #412 BRAID: Our proprietary braid was designed to be used in equivalent amounts to carbon. Coyote Composite is more flexible than carbon (we consider this to be an advantage), but if you need to match the rigidity of a carbon socket, use additional layers of stockinette and/or carbon tape. • Extremely durable • Resistant to cracking • Less itch than carbon • Noncarcinogenic and nontoxic • Strong and lightweight • Finishes smooth, with superior resin saturation • Unique dampening characteristics • Less expensive. For more information, contact Coyote Design at 208/429-0026 or visit coyotedesign.com.

Coyote Design: Composite Fabric

BOOTH #412 Coyote Composite is a great alternative to itchy, expensive carbon fiber! Coyote Composite, made from basalt filament, is a safe, tough material for composite sockets and ankle-foot orthoses (AFOs). Also relatively easy to cut and finish compared to other materials. FABRIC: Coyote Composite fabric sheeting can be used for reinforcement layers of heavy-duty sockets and/or AFOs. The material is thin and lightweight, which allows for greater flexibility in adding the ideal amount of reinforcement. For more information, contact Coyote Design at 208/429-0026 or visit coyotedesign.com.

O&P ALMANAC | OCTOBER 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.

Coyote Design: New Solid Brass Pins BOOTH #412 Coyote Design has introduced two new heavy-duty solid brass pin options for its Air-Lock and Easy-Off Lock lines. Coyote found the new brass pins are more durable, have less deflection, and have exceptional wear characteristics. These pins increase the Air-Lock weight capacity from 265 lbs to 350 lbs. Like most Coyote products, the pins are noncorrosive and water resistant, making them great for active people and heavier weight patients. The pins helps eliminate noise issues. • CD103P8H (Eight-Click Brass Pin) • CD103P11H (Eleven-Click Brass Pin) • CD103H (Air-Lock With Brass Pin) For more information, contact Coyote Design at 208/429-0026 or visit coyotedesign.com.

Coyote Design: Coyote Quick Adhesive BOOTH #412 We use Coyote Quick Adhesive in the fabrication of our prosthetic locks, socket adapters, and valves. • Attaching componentry • Repairing sockets • Very quick to set with no sag • Ships nonhazardous • Safe to use and has no odor. Coyote Quick Adhesive works in any situation when you need something glued quickly and easily. For more information, contact Coyote Design at 208/429-0026 or visit coyotedesign.com.

New Sure Stance Knee by DAW BOOTH #381 This ultralight, true-variable cadence, multiaxis knee is the world’s first four-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 K3 patients. For more information, contact DAW Industries Inc. at 800/252-2828, email info@daw-usa.com, or visit www.daw-usa.com. 72

OCTOBER 2015 | O&P ALMANAC

DawSkin New Mega Stretch BOOTH #381 DawSkin New MegaStretch is the most durable tear-free skin in the world. It is the ideal skin for your patient to shower on both legs (definitely the safer way). DawSkin MegaStretch provides the vertical ankle stretch required for multiaxis feet and energy restitution feet. “Heat-shrink” skins limit the ankle movement and will tear. DawSkin New EZ-Access dons on and off just like a sock yet provides all of the benefits of the DawSkin New MegaStretch. For more information, contact DAW Industries Inc. at 800/252-2828, email info@daw-usa.com, or visit www.daw-usa.com.

ePAD: The Electronic Precision Alignment Device BOOTH #381 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 self-leveling 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.

Dual Purpose Expansion Arbors BOOTH #102 Introducing the Dual Purpose Expansion Arbors from Fillauer: These arbors combine the patent-pending technology of our expansion arbors with the power of our polishing arbors, allowing you to sand and polish without changing tools. Contact Fillauer or your preferred O&P distributor to place your order today! For more information, call Fillauer at 800/251-6398, 423/624-0946, or visit www.fillauer.com.

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MARKETPLACE

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

Introducing the Stronger, Smarter, Submersible Plié® 3 MPC Knee BOOTH #237 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

BOOTH #237 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. 74

OCTOBER 2015 | O&P ALMANAC

LEAP Balance Brace BOOTH #237 Hersco’s Lower-Extremity Ankle Protection (LEAP) brace is designed to aid stability and proprioception for patients at risk for trips and falls. The LEAP is a short, semirigid ankle-foot orthosis that is functionally balanced to support the foot and ankle complex. It is fully lined with a lightweight and cushioning Velcloth interface, and is easily secured and removed with two Velcro straps and a padded tongue. For more information, contact at 800/301-8275 or visit www.hersco.com.

Orthomerica: Prosthetic Custom Fabrication BOOTH #245 & #249 Orthomerica Products Inc. is pleased to introduce Prosthetic Custom Fabrication. First-stage and second-stage sockets. Check, BK, and AK sockets are available with a three- to five-day turnaround time. All modifications and fabrications available. Most scans and casts accepted. For more information, visit www.orthomerica.com.

Register To Attend the Össur® International Prosthetic Symposium BOOTH #401 Please join us for our first International Prosthetic Symposium at our stateof-the-art Össur Academy facility in Orlando. The three-day Symposium, which will focus on rehabilitation and prosthetic solutions for the low-active amputee, will be held November 19-21. The program will feature a variety of experts—George Hipp, MD; Jeffry Pirofsky, DO; Chris Ireland, PT, DPT, OCS; and Glenn Crumpton, LPO—and the agenda will cover several important topics, including postoperative solutions, rehabilitation, prosthetic technology, elevated vacuum, osteoarthritis, and diabetes. Contact your Össur® representative today, or visit www.ossur.com/ips5 to download the full agenda and register.

Regain Confidence

EasySkin

Protective Cosmetic Cover Regain conďŹ dence with the ALPS EasySkin cosmetic covers. These covers are highly conformable, pre-stretched and have no transition line at the ankle. Ideal for transtibial patients; available in 7 shades and two sizes to accommodate more users. Simply heat shrink for easy application.

Tel: 727.528.8566

Tel: 800.574.5426

www.easyliner.com

info@easyliner.com

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.

Ottobock’s New 3R106 Pro Polycentric Pneumatic Knee BOOTH #201 The key element of the new 3R106 Pro is the servo-pneumatic control unit. Its powerful dual-chamber pneumatic unit with progressive damping has a flexion valve set for the patient’s normal walking speed. At faster walking speeds, the flexion resistance increases, which prevents too much knee flexion. This helps provide more consistent swing phase even during fast walking. With three options for the proximal connection (pyramid, threaded connector, and lamination anchor) and a 275-lb weight limit, the 3R106 Pro offers you great fitting options. For more information, contact your sales representative at 800/328-4058 or visit ottobockus.com.

New AxonHook From Ottobock BOOTH #201 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 local sales reps at 800/328-4058 or logging onto www.professionals.ottobockus.com.

Ottobock: 28U90 Ankle-Foot Orthosis BOOTH #201 The 28U90 ankle-foot orthosis from Ottobock blocks foot drop during swing phase. Its thin-walled polypropylene construction has been optimized for increased resilience, providing effective support in an incredibly lightweight orthosis. The long sole provides precise foot guidance and good pressure distribution. New calf pads and closure straps are included and ensure a high level of wearer comfort. These can be adapted without additional tools. Ask your sales rep at 800/328-4058 about how the 28U90 can help your patients.

OCTOBER 2015 | O&P ALMANAC

Spinal Technology BOOTH #137 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.

PressureGuardian Developed by Tillges Technologies LLC BOOTH #369 PressureGuardian® technology combines instantaneous pressure load measurement with a compatible data collecting and storing app. PressureGuardian comes with a four-sensor lead to monitor up-to-four sites on the body instantaneously. This tool helps clinicians manage their patients’ challenging diabetic wounds with astonishing results and is able to advance the healing process. PressureGuardian can also be used to measure pressure loads inside prosthetic sockets and orthotic devices to ensure they are being fit properly. New sensor calibration feature added in 2015! To learn more about PressureGuardian and our central fabrication products, visit us at Booth #369 at the AOPA Assembly or visit www.pressureguardian.com.

FOR SALE: O&P TOOLS O&P tools such as a vertical jig, like-new Trautman Carver, AK joints foots, Ottobock components, back and knee braces, A to Z tools for an O&P shop and every material to run a shop. For more information, contact 516/647-9400.

MARKETPLACE

Turbomed: Walk, Run, Jog, Hike…Don’t Be Limited! BOOTH #568 Turbomed Orthotics introduces the revolutionary FS3000 foot drop ankle-foot orthosis (AFO). This stunning, new AFO redefines comfort and freedom. The patented design, using an outside-of-the-shoe approach, gives new possibilities to patients with foot drop that they never thought possible. Features and benefits include: • 100 percent transferable • 100 percent outside of the shoe • As lightweight as a carbon fiber AFO • No contact with the foot or the ankle • Amazing energy return due to the patented design • Best warranty on the market. Try the FS3000 for two months, and if you are not satisfied for any reason, return it for a full refund. For more information, contact Turbomed Orthotics at 418/563-8675 or visit www.turbomedorthotics.com.

Membership has its benefits:

BUILD A

Better

2015 AOPA Coding Products BOOTH #637 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, easy-to-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.

CO-POLYMER

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BUSINESS WITH AOPA

Visit www.AOPAnet.org/join today! Learn how AOPA can help you transform your business into a world class provider of O&P Services with: Coding, Billing and Audit Resources Education, Networking, and CE Opportunities

Stop by booth #333 at the AOPA National Assembly

Advocacy Research and Publications Business Discounts

3535 Route 66, Bldg. #4 Neptune, NJ 07753-2625 800-342-2602 (732) 918-8115 Fax: (732) 918-1131

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O&P ALMANAC | OCTOBER 2015

AOPA NEWS

CAREERS

Opportunities for O&P Professionals

Certified Prosthetist-Orthotist, Certified Prosthetist, and Certified Orthotist

Job location key: - Northeast - Mid-Atlantic - Southeast - North Central - Inter-Mountain - Pacific

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

Southeast 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 résumé to:

Email: sethwalters@excel-prosthetics.com 78

Pacific

OCTOBER 2015 | O&P ALMANAC

Orange County, Riverside County, and San Bernardino County, California Here we grow again: 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 résumé to:

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

Northeast Certified Prosthetist-Orthotist, Certified Prosthetist, and Certified Orthotist

Watertown, New York A well-established, multioffice practice has immediate openings for residents and ABC-certified CPOs/ CPs/ COs. Candidates must be motivated individuals who possess a strong clinical presence, technical experience, the ability to document all aspects of patient contact, and the desire to improve the quality of life for those who require our services. Northern Orthopedic Laboratory is based in Watertown, New York, located on the outskirts of scenic Lake Ontario and St. Lawrence River. We offer a competitive salary (commensurate with experience), medical, dental, vision, 401K, and profit sharing. Send résumé to:

Northern Orthopedic Laboratory Inc. 1012 Washington Street Watertown, NY 13601 Office: 315/782-9098 Email: nolcpo@aol.com www.northernorthopediclaboratory.com

Materials for Milling Orthotics 17”

37”

40 dur Black Microcel Puff®

55 dur Natural Multicork™

SLSTRP-00693

SLSTRP-00396

40 dur White Microcel Puff® SLSTRP-00628

• 17” x 37” strip size • 31.5mm (~1¼”) slopes down to 6.5mm (~¼”) • Each Slope Strip will yield 3 pairs of orthotics! • Skived blocker reduces wasted material (less dust) • Faster milling time • More cost effective • Custom sizes available to fit your milling table

Call today for a free sample!

38mm MATERIALS

• 37” x 70” sheets • 38mm (~1½”) material, thickest available

40 dur Black Microcel Puff® PUFF-00693

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800-237-2267

CALENDAR fitters, therapeutic shoe fitters, orthotic and prosthetic assistants, and orthotic and prosthetic technicians. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.

2015

November 4-6 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

November 1

ABC: Application Deadline for Certification Exams. Applications must be received by November 1 for individuals seeking to take the January ABC certification exams for orthotists, prosthetists, pedorthists, orthotic fitters, mastectomy

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 6

COPA & UCSF: Orthotic and Prosthetic Innovation & Technology Symposium. Driving the Future of O&P—Connecting Innovators and Investors. Millberry Union Event & Meeting Center, University of California—San Francisco. Register at www.californiaoandp.com/Education. For more information, contact 415/206-8813, or email erin.simon@ucsf.edu.

November 9-10

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

November 9-14

ABC: Written and Written Simulation Certification Exams. ABC certification exams will be administered for orthotists, prosthetists, pedorthists, orthotic fitters, mastectomy fitters, therapeutic shoe fitters, orthotic and prosthetic assisants and technicians in 250 locations nationwide. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.

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.

OCTOBER 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 26-50 51+

$40

$50

1/4 page Ad

$482

$678

$50

$60

1/2 page Ad

$634

$830

$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.

INTERNATIONAL PROSTHETIC SYMPOSIUM Rehabilitation and Prosthetic Solutions for the Low Activity Amputee November 19 - 21, 2015 • Össur Academy • Orlando, Florida Join us for this unique event featuring key opinion leaders focusing on Rehabilitation and Prosthetic Solutions for the Low Activity Amputee. The Program is intended for multi-disciplinary teams active in the field of amputee rehabilitation and will explore the unique needs of low active amputees, as well as prosthetic solutions available to improve patient outcomes.

TOPICS AND SPEAKERS INCLUDE THE FOLLOWING The Need for an Integrated Team Approach to Prosthetic Management

Evidence-Based Amputee Rehabilitation (EBAR) of the Elderly Person with Limb Loss Robert S. Gailey, PhD, PT

A review of the multi-disciplinary approach to the management of amputee care. Each member of an amputee's rehabilitation team — surgeon, PM&R physician, PT, prosthetist — will influence the rehabilitation process and prosthetic selection. Together, these specialists focus on optimizing outcomes based on patient needs, medical necessity and desired outcomes within the constraints of legal compliance. George E. Hipp, MD Jeffry G. Pirofsky, DO Chris Ireland, DPT, OCS, PT Glenn Crumpton, LPO, CEO

Lower Limb Amputation Due to Vascular Problems: Surgical and Rehabilitation Aspects Jan HB Geertzen, MD, PhD

Osteoarthritis in the Low Active Amputee Katherine Dec CAQSM, FAAPMR, MD

SPACE IS LIMITED! View the full agenda and register today ossur.com/ips4 TEL (800) 233-6263 FAX (800) 831-3160 WWW.OSSUR.COM

CALENDAR November 11

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

December 1

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

December 3-5

R.I.C: Elaine Owen. Pediatric Gait Analysis: Segmental Kinematic Approach to Orthotic Management. Chicago. 22.0 ABC credits. Contact Melissa Kolski at 312/238-7731 or visit www.ric.org/education.

December 9

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

2016 September 8-11, 2016 99th AOPA National Assembly. Boston. For exhibitors and sponsorship opportunities, contact Kelly Oâ&#x20AC;&#x2122;Neill at 571/431-0852 or koneill@AOPAnet.org. For general inquiries, contact Betty Leppin at 571/431-0876, or bleppin@AOPAnet.org, or visit www.AOPAnet.org.

ADVERTISERS INDEX

Company

Page Phone

Website

ACOR Orthopedics Inc. Allard USA ALPS South LLC Amfit Amputee Coalition Arizona AFO Inc. ARTech Laboratory Inc. Becker Orthopedic Board of Certification/Accreditation The Bremer Group Company Cailor Fleming Insurance Cascade Dafo College Park Industries ComfortFit Labs Inc. Coyote Design Custom Composite DAW Industries Delcam Healthcare Solutions Ferrier Coupler Inc. Fillauer Flo-Tech O&P Systems Inc. Freedom Innovations Hersco JMS Plastics Supply Kingsley Manufacturing Orthomerica Ă&#x2013;ssur Americas Inc. Ottobock Spinal Technology Inc. Tillges Technologies Touch Bionics Turbomed Orthotics

9, 79 800-237-2276 51 888-678-6548 13, 75 800-574-5426 57 800-356-3668 61 43 877-780-8382 63 888-775-5501 Insert 800-521-2192 59 877-776-2200 17 800-428-2304 5 800-796-8495 19 800-848-7332 35 800-728-7950 27, 56 888-523-1600 7, 65 800-819-5980 23 866-273-2230 1, 73 800-252-2828 29 877-335-2261 18 810-688-4292 55 800-251-6398 37 800-356-8324 25 888-818-6777 2 800-301-8275 77 800-342-2602 67 800-854-3479 21 800-446-6770 11, 81 800-233-6263 45, C4 800-328-4058 15 800-253-7868 53 855-484-5832 47 855-694-5462 38-39 stephaness2@hotmail.com

www.acor.com www.allardusa.com www.easyliner.com www.amfit.com www.amputee-coalition www.arizonaafo.com www.artechlab-prosthetics.com www.beckerorthopedic.net www.bocusa.org www.bremergroup.com www.cailorfleming.com www.cascadedafo.com www.college-park.com www.comfortfitlabs.com www.coyotedesign.com www.cc-mfg.com www.daw-usa.com www.orthotics-cadcam.com www.ferrier.coupler.com www.fillauer.com www.1800flo-tech.com www.freedom-innovations.com www.hersco.com www.jmsplastics.com www.kingsleymfg.com www.orthomerica.com www.ossur.com www.professionals.ottobockus.com www.spinaltech.com www.tillgestechnologies.com www.touchbionics.com www.turbomedorthotics.com

OCTOBER 2015 | O&P ALMANAC

BOSTON 2016 AOPANET.ORG

Mark your calendars September 8-11, 2016, for an ideal combination of top-notch education and entertainment at the combined 99th AOPA National Assembly and New England Chapter Meeting in Boston, MA. We look forward to seeing you in 2016!

EXCELLENCE in EDUCATION Prosthetic

Orthotic

Pedorthic

Technical

Business

For information about the show, scan the QR code with a code reader on your smartphone or visit www.AOPAnet.org.

ASK AOPA

Nurse Practitioner Knowledge Guidelines for nurse practitioners’ official signatures

AOPA receives hundreds of queries from readers Q and members who have questions about some aspect of the O&P industry. Each month, we’ll share several of these questions and answers from AOPA’s expert staff with readers. If you would like to submit a question to AOPA for possible inclusion in the department, email Editor Josephine Rossi at jrossi@contentcommunicators.com.

Is it acceptable for nurse practitioners to create and sign a detailed written order?

Yes. Nurse practitioners may document the need for Medicare-covered benefits; thus, they are eligible to write and sign orders or prescriptions—both initial orders and final detailed written orders. However, several criteria must be met: • The nurse practitioner must be treating the beneficiary for the condition for which the item or service is required. • The nurse practitioner must be practicing independently of a physician. He or she may work with a physician as part of a group practice or under the physician, but he or she must be working independently. • The nurse practitioner must have his or her own national provider identifier (NPI) number, and must be billing Medicare for other covered services using his or her own NPI number. • The nurse practitioner must be permitted to practice in the state in which he or she is providing services.

Is it acceptable for nurse practitioners to sign the certifying statement for diabetic shoes?

Unfortunately, nurse practitioners may not sign these certifying statements—and this is not a discredit to a nurse practitioner’s education and skills. The Therapeutic Shoes for Persons With Diabetes Policy clearly states that the person signing the certifying statement for diabetic shoes must be a medical doctor (MD)

OCTOBER 2015 | O&P ALMANAC

or a doctor of osteopathy (DO), and the MD or DO must be treating patients for diabetes. This requirement is written into the Social Security Act, which outlines the benefits for diabetic shoes—so it would take an act of Congress to allow nurse practitioners to sign the certifying statements. Nurse practitioners may document the need for the diabetic shoes and the patient’s secondary foot condition, but their findings must be signed off by the certifying physician. In a hospital/clinic/rehab setting, if a patient is unable to sign a proof of delivery, may a nurse practitioner sign for the patient?

Yes, it is acceptable for a nurse practitioner to sign a proof of delivery on behalf of a patient if the patient is unable to sign. Almost anyone may sign on behalf of a patient if the patient is unable to sign. The only people who may not sign on behalf of a patient are those individuals who have a direct financial interest in the payment of the claim, which includes the orthotist/ prosthetist and his or her staff. If someone other than the patient signs the delivery slip, you should take several precautions. First, document who is signing for the patient and why he or she is signing for the patient. Also document the relationship of the person signing the proof of delivery to the patient. Finally, be sure the person signing on behalf of the patient has clearly written his or her name, or be sure the name is on file, just in case you have to track down the person who signed the delivery slip at a later date.

The Source for Orthotic & Prosthetic Coding

The O&P expertise you’ve come to rely on is now available 24 hours a day. Match products to L codes and manufacturers—anywhere you connect to the Internet. This exclusive service is only available for AOPA members.

Here is what AOPA members are saying:

“LCode Search.com is my go to resource for quick and accurate coding advice.” “It’s one convenient location for codes and fees, so it saves me time and money.” “Coding for common devices is at my fingertips.”

Get Connected! Need to renew your membership? Contact Betty Leppin at 571/431-0876 or bleppin@AOPAnet.org. www.AOPAnet.org

Supplier Members: For information on listing your products, contact Devon Bernard at 571/431-0876, x254, or by email at dbernard@AOPAnet.org.

C-Leg 4

Orion 2

Plié 3

Rheo 3

Clinically proven stumble recovery1 Reliable stance release on challenging surfaces Real time swing and stance control No charge reimbursement support PDAC verified2 User smartphone app IP rating3

Adjustable modes for special activities Default stance for increased safety No fixed service intervals Knee stability when walking backwards Stance control on stairs, ramps and across all terrain Dual standing functions Years on market4

Clinical publications4

1 C-Leg 4: International C-Leg Studies, published by Otto Bock HealthCare GmbH, 3rd Edition, 2014, 646B33=GB-05-1403; Rheo 3: In some situations, stumble recovery requires increased compensatory movements therefore it is not as effective as C-Leg. Bellman M, Schmalz T, Blumentritt S.,“Comparative biomechanical analysis of current microprocessor-controlled prosthetic knee joints.”, Arch Phys Med Rehabil 2010; 91:644-52. 2 L5828, L5845, L5848, L5856 and L5930 are verified. L5850, L5925 and L5999 are pending verification. 3 As stated in international standard IEC 60529, IP or Ingress Protection rating refers to the degree of protection provided against the intrusion of solid objects, dust, accidental contact and water in electrical enclosures. 4 Includes all product versions. Sources: www.endolite.com/products/orion2, www.freedom-innovations.com/plie3, www.ossur.com/prosthetic-solutions/products/knees-and-legs/bionic-knees/rheo-knee-3

Dare to compare

C-Leg® 4 microprocessor knee You and your patients will experience the difference, from personalized reimbursement support to walking backwards with confidence. To get the details, please contact your Sales Rep at 800 328 4058 in the US or 800 665 3327 in Canada. Or, visit Ottobockus.com and Ottobock.ca for easy online qualification.

ottobockus.com | ottobock.ca