October 2016 O&P Almanac by AOPA

The Magazine for the Orthotics & Prosthetics Profession

O CTO B E R 2016

E! QU IZ M

The Ins and Outs of Inpatient Billing

EARN

CREDITS P.20 & 53

P.18

Caring for Veterans of All Ages P.34

2016 National Assembly Keynote Highlights P.42

Tips for Complying with the DMEPOS Supplier Standards

BUSINESS CE

Smart STAFFING

HOW CARE EXTENDERS CAN HELP TO OPTIMIZE BUSINESS PRACTICES IN A DEMANDING REIMBURSEMENT ENVIRONMENT P.26

WWW.AOPANET.ORG

P. 48

This Just In: AOPA Urges Recoupment Delay Until ALJ Rules P.22

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Mark your calendars September 6-9, 2017, for an ideal combination of top-notch education and entertainment at the combined 100th AOPA National Assembly and World Congress Meeting in Las Vegas. We look forward to seeing you in 2017!

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contents

MONTH 2016 | VOL. 65, NO. 10

COVER STORY

FEATURES

DEPARTMENTS | COLUMNS Views From AOPA Leadership ........ 4

Reflections on the 2016 National Assembly

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

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

At-a-glance statistics and data

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

Research, updates, and industry news

People & Places ....................................... 16

Transitions in the profession

26 | Smart Staﬃng Assistants, fitters, technicians, and other care extenders are playing important roles in today's O&P facilities under the supervision of certified orthotists and prosthetists. Hiring these positions may help promote efficiencies and ensure clinicians make the most of their face time with patients. By Christine Umbrell

22 | This Just In

P. 22

By Christine Umbrell

42 | Two Keynotes, One Message :

Participate!

At the 2016 AOPA National Assembly, two well-respected political figures—former Sen. Bob Kerrey (D-Nebraska) and CNN Senior Political Analyst David Gergen—offered insights on current events, the upcoming presidential elections, and the future of O&P.

Compensation for inpatient services

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

Compliance Corner ............................. 48

Dissecting the Standards

Tips for complying with the Supplier Standards

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

The Office of Medicare Hearings and Appeals has developed a plan of action to address the delays in administrative law judge hearings for claims appeals.

Both combat-injured service members and aging veterans may require O&P intervention to return to their activities of daily living. Clinicians working with the various generations should be sensitive to patients’ needs and activity goals, work in a collaborative approach, and select components carefully. Plus: Q&A With Clinicians at Walter Reed National Military Medical Center

Make the Most of Inpatient Billing CREDITS

AOPA Urges Recoupment Delay Until ALJ Rules

34 | An Honor To Serve

Reimbursement Page ......................... 18

CREDITS

Member Spotlight ................................ 54 ■

P. 34

■

Advanced Orthotic Designs Martin Bionics

AOPA News............................................... 58

AOPA meetings, announcements, member benefits, and more

Welcome New Members ................ 60

PAC Update ............................................... 61

P. 42

Marketplace ............................................. 62

Ad Index...................................................... 65 Careers ........................................................66

Professional opportunities

Calendar ..................................................... 67

Upcoming meetings and events

Ask AOPA ..................................................68 Changing your participation status with Medicare

O&P ALMANAC | OCTOBER 2016

VIEWS FROM AOPA LEADERSHIP

An Inspirational Assembly

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

This month, O&P Almanac asked three members of the 2016 AOPA National Assembly Planning Committee to reflect on this year’s seminal event.

Business Sessions Highlight O&P Evolution

Based on the clinical and business educational sessions that I attended at the 2016 AOPA National Assembly, and the feedback that I received from many attendees, this year’s event truly delivered on the meeting’s theme of “Lighting the Future.” The clinical and business content of the Assembly’s programming provided the Assembly’s attendees with a “beacon of light” to navigate the uncertain waters of today’s health-care environment. Russell Hornfisher, MBA, set the tone with his presentation, “This Isn’t Your Father’s O&P.” Hornfisher provided evidence to support the notion that O&P business owners and clinicians must possess some nontraditional O&P skills— skills that were not needed in the past—to succeed in today’s medical economy. Eric Burns, CO, one of this year’s Hamontree Lecture Series presenters, talked about the renaissance occurring as a result of new technology, research, and the O&P profession’s positive impact on patient-care outcomes. This year’s Assembly provided information and tools that will enable attendees to provide cost-effective O&P products and services that improve patient outcomes and effectively manage the non-patient-care challenges they are facing. —Frank H. Bostock, CO, FAAOP

Clinical Sessions Offer Innovative Solutions

OFFICERS

President James Campbell, PhD, CO, FAAOP Hanger Clinic, Austin, TX President-Elect Michael Oros, CPO, FAAOP Scheck and Siress O&P Inc., Oakbrook Terrace, IL Vice President James Weber, MBA Prosthetic & Orthotic Care Inc., St. Louis, MO Immediate Past President Charles H. Dankmeyer Jr., CPO Arnold, MD

Having logged about 36 years of active clinical involvement in the field and about 22 years in volunteer leadership roles, first at the AAOP and then at AOPA, I have the luxury of retrospect, and I can say unequivocally that the quality of the scientific papers, symposia, and instructional courses were better than they have ever been before, and light years ahead of where we were in the early 1980s. As we strive for better content at our meetings each year, I suspect that we sometimes fail to look back and fully appreciate how far we have come. In the May issue of the O&P Almanac, President-Elect Michael Oros, CPO, FAAOP, wrote about the courage shown by a selected group of visionaries at NCOPE in driving forward a plan for implementing a master’s level minimum educational requirement for the profession. That step, more that any that I can recall in my career, has changed the field, and it has had a direct impact on the quality of the science being presented at our meetings today. This year’s Assembly reached a new pinnacle in the quality of its clinical content. From the poster exhibits to the Thranhardt lectures, the content was excellent, and next year’s World Congress will be even better. —Thomas V. DiBello, CO, LO, FAAOP

Treasurer Jeff Collins, CPA Cascade Orthopedic Supply Inc., Chico, CA

Marketing and Promotions Hit the Mark

Pam Lupo, CO Wright & Filippis and Carolina Orthotics & Prosthetics Board of Directors, Royal Oak, MI

In recent years, the AOPA Planning Committee Marketing Team has worked to engage the entire membership and keep the AOPA conference a relevant and valuable event. We used the results of surveys and group activities to focus our innovation efforts on program content and networking opportunities, then identified how we could build more effective promotions, working closely with AOPA staff. Examples include the evolution of the Alumni Connection and Women in O&P initiatives. The introduction of more technology solutions, such as the AOPA 365 app, has enabled more direct interactions between members as well as improved communications. From a promotions perspective, we have used historic data to determine which geographies to target for different meetings and how to segment the program content to different audiences using a mix of traditional and digital channels. All of these efforts contributed to a truly amazing experience for attendees at this year’s Assembly. —Anthony Potter, MBA 4

Board of Directors

OCTOBER 2016 | O&P ALMANAC

Executive Director/Secretary Thomas F. Fise, JD AOPA, Alexandria, VA DIRECTORS David A. Boone, BSPO, MPH, PhD Orthocare Innovations LLC, Mountain Lake Terrace, WA Maynard Carkhuff Freedom Innovations LLC, Irvine, CA Eileen Levis Orthologix LLC, Trevose, PA

Jeffrey Lutz, CPO Hanger Clinic, Lafayette, LA Dave McGill Össur Americas, Foothill Ranch, CA Chris Nolan Ottobock, Austin, TX Bradley N. Ruhl Ottobock, Austin, TX

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

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 Carlson, CMP, senior director of membership operations and meetings, 571/431-0808, tcarlson@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

Devon Bernard, assistant director of coding and reimbursement services, education, and programming, 571/431-0854, dbernard@ AOPAnet.org SPECIAL PROJECTS Ashlie White, MA, manager of projects, 571/431-0812, awhite@AOPAnet.org Reimbursement/Coding: 571/431-0833, www.LCodeSearch.com

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

Yelena Mazur, membership and meetings coordinator, 571/431-0876, ymazur@AOPAnet.org

Josephine Rossi, editor, 703/662-5828, jrossi@contentcommunicators.com

Ryan Gleeson, meetings coordinator, 571/431-0876, rgleeson@AOPAnet.org

Catherine Marinoff, art director, 786/293-1577, catherine@marinoﬀdesign.com

AOPA Bookstore: 571/431-0865

Bob Heiman, director of sales, 856/673-4000, bob.rhmedia@comcast.net Christine Umbrell, editorial/production associate and contributing writer, 703/6625828, cumbrell@contentcommunicators.com

OCTOBER 2016 | O&P ALMANAC

Publisher Thomas F. Fise, JD

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 © 2016 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 more than 13,000 subscribers. Engage the profession today. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net. Visit bit.ly/aopamediakit for advertising options!

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NUMBERS

O&P Productivity: How Do You Stack Up? AOPA’s 2016 Operating Performance

REVENUES FOR FY2015

Report, based on 2015 data, captured the financial facts from 88 companies representing 1,164 full-time facilities and 71 part-time facilities. The data indicates a 7 percent increase in net sales versus the previous year.

PERCENT OF SALES BY CATEGORY Durable medical equipment

Median revenue per nonowner practitioner, up from $476,000 in FY2014.

EMPLOYEE MAKEUP BY CATEGORY

Owner practitioners

Prosthetics

5% 1% 4%

Other job titles

Nonclinical owners/ managers

8% 3% 2% 2%

Technicians

41%

49%

Oﬃce administration/ marketing staff

38%

14%

Nonowner practitioners

PERCENTAGE INCREASE IN NET SALES/BILLINGS IN 2015 VS. 2014

33%

FY2014

FY2015

Up to $1 Million

7.1%

9.1%

$1 to $2 Million

3.1%

9.3%

$2 to $5 Million

5.7%

4.8%

Over $5 Million

5.7%

7.0%

OCTOBER 2016 | O&P ALMANAC

Increase over previous year for profit leaders (top 25 percent of respondents, based on 2015 return on assets performance).

5.5 Percent

11.5 Percent

Company Size

SOURCE: AOPA's 2016 Operating Performance Report.

11.7 Percent

Increase over previous year for companies with less than $1 million in sales.

O&P FACILITY NET PROFIT MARGINS

Median revenue per employee, compared to $165,000 in FY2014.

Practitioner assistants/extenders

Other

Pedorthics Orthotics

$510,836 $162,987

Increase over previous year for companies with more than $5 million in sales.

Editor’s Note: The 2016 Operating Performance Report is now available through the AOPA bookstore. Visit www.aopanet.org.

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Happenings LATEST LEGISLATION

O&P Stakeholders Urged To Contact Lawmakers as Vote Nears • • •

• •

Recognizes the value of the orthotist’s or prosthetist’s notes in the medical record. Assures due process rights to proper administrative law judge timeframes. Reinstates and clarifies the statutory definition of “minimal self-adjustment” for off-the-shelf orthoses to protect Medicare beneficiaries. Distinguishes orthotists and prosthetists from suppliers of durable medical equipment. Reiterates the urgency for CMS to implement by regulation the qualified provider/licensure/ accreditation mandate of Section 427 in the Benefits Improvement and Protection Act.

During and prior to the recent AOPA National Assembly, more than 600 individuals sent emails to their legislators urging them to support S. 829 and H.R. 1530. If you haven’t done so already, AOPA asks that you visit www.AOPAvotes.org and follow the steps to send similar emails to your legislators. Your participation can make a difference.

PHOTO:iStock.com/amedved

AOPA members and O&P advocates can take advantage of a small window of opportunity to secure a congressional victory during the next vote on the Medicare Orthotic and Prosthetic Improvement Act (S. 829 and H.R. 1530). Right now, the stars are aligned: CMS has offered its assurance that it will not oppose the legislation, the Congressional Budget Office (CBO) has provided a zero score, and the bill has been deemed noncontroversial—meaning there is no partisan opposition. The CBO score may be the clincher, as a zero score means no economic impact— good or bad—on the budget, which overcomes one of the most intransigent obstacles to any legislative proposal. To come this far and not secure final approval when it is within our grasp would be a very sad ending, but a possible one if we can’t secure sufficient legislator attention. This legislation reduces fraud and more properly aligns provider qualifications to patient needs. In addition, it supports the middle-class, small businesses that these prosthetic practices operate, and saves federal health dollars. The bill also accomplishes the following:

Prepping for the Election

OCTOBER 2016 | O&P ALMANAC

to access a packet of materials to assist you in this process. Congress has probably made the mad dash out of Washington by the time you are reading this, and the vote may take place during the “lame duck” session that is expected, but not guaranteed, to convene after the election. It is not too late for you to push the www.AOPAvotes.org “Send” button.

PHOTO:iStock.com/Rawpixel Ltd.

During the last few weeks of this election cycle, there will be candidate events, opportunities to volunteer for candidates, and, most importantly, opportunities to host legislators on your home turf. To host a legislator, contact his or her nearest district office to request a “show and tell” visit, where your patients can serve as spokespersons for the cause. Contact AOPA

HAPPENINGS

RESEARCH ROUNDUP

Patients With Spinal Injury Regain Some Feeling Via Training

PHOTO: AASDAP, São Paulo, Brazil

Researchers in Brazil have found that damaged spinal tissue in some people with paraplegia can be retrained. In a study published in the August issue of Scientific Reports, researchers led eight spinal cord injury paraplegics in brain training exercises while they interacted with specially designed exoskeletons, and found the subjects were able to regain some sensation and movement. The study participants, who had been paralyzed for a time period between three and 13 years, underwent 12 months of training with a multistage gait neurorehabilitation paradigm based on brain-machine interface training. While the paralyzed subjects in the Brazilian study did not regain enough mobility to support their weight on their legs, they did make a “partial recovery,” said Miguel Nicolelis, MD, PhD, a professor of neuroscience at the Duke School of Medicine and founder of the international Walk Again Project, who led the research. The study subjects recovered some sensation, voluntary muscle contraction, and control over bowel and bladder functions, all of which improved their quality of life. In addition, one woman was able to deliver a baby vaginally. “She could feel the baby for the first time,” said Nicolelis. “She could feel the contractions.” The researchers compared the improvements in mobility to the way

some individuals with brain injury regain partial brain function following stroke through repetition and practice. Nicolelis and his team trained the subjects to visualize moving their muscles, by having them wear virtual reality goggles and giving them tactile feedback on their arms. This exercise helped to create brain signals that could be picked up by electrodes and used to control an exoskeleton. The study subjects also took part in physical therapy and extensive stimulation as the robotic machines moved their muscles. As the study participants improved their ability to visualize limb movements, they also regained some feeling and movement as well. “For the first time in many years, they were able to voluntarily control their muscles,” said Nicolelis. Some subjects had their level of paralysis upgraded to a less severe rating of “incomplete paraplegia.” The two study participants who had been paralyzed for more than a decade showed the most improvement, according to Nicolelis: They “can generate leg movements, move their legs out and in, and flex their knees,” he said. The study findings raise the possibility that more prolonged efforts to restore some movement in paralyzed people could pay off, according to the researchers. Nicolelis is planning to expand his research to a new study group.

O&P ADVOCACY

Congressman Visits Pennsylvania Facility Rep. Ryan Costello (R-Pennsylvania), representing the Sixth District of Pennsylvania, visited the corporate oﬃce of Ability Prosthetics & Orthotics Exton on August 17. Costello met with Ability’s founder, Jeffrey M. Brandt, CPO, and three belowknee amputee patients. Brandt and the amputees shared their thoughts on how key legislative issues, such as H.R. 1530 and H.R. 5045, may have an impact on prosthetic care for the future.

Rep. Ryan Costello (R-Pennsylvania), far right, visited Ability Prosthetics & Orthotics to meet with Ability’s founder and chief executive oﬃcer, Jeffrey M. Brandt, CPO, second from left, and several patients.

O&P ALMANAC | OCTOBER 2016

HAPPENINGS

RESEARCH ROUNDUP

Take a Survey on O&P Research Priorities

Trauma Surgeons Suggest Through-Knee Amputations for Landmine Victims

The British Columbia Institute of Technology (BCIT) is conducting a short survey on research topics to benefit practitioners and those who use prosthetic and orthotic devices. Everyone who participates in the survey, which is expected to take 10 to 15 minutes to complete, will receive a copy of the survey results once the survey is completed. PROJECT TITLE:

Prosthetics and Orthotics: Feedback on Research Priorities PRINCIPAL INVESTIGATOR:

Silvia Raschke, PhD, BCIT PURPOSE:

To establish a research strategy and platform that identifies needs and priorities in the field of prosthetics and orthotics, and to examine people’s perceptions regarding what research topics would be of most benefit to clinical practitioners and those who use prosthetic and orthotic devices.

OCTOBER 2016 | O&P ALMANAC

the distal femur,” said Bull. “This is because the key component is the ability to load bear through the healed stump, and it is often painful taking weight on soft tissue abutting the end of a thigh bone where it has been cut.” Bull also noted above-knee amputations require that some of the connections of the adductor muscles be cut, which can hinder future walking on a prosthetic limb since these muscles prevent the legs from swinging outward. Bull and other trauma surgeons agreed during the conference that amputation through the knee joint may be preferable in order to maintain the distal femur, to improve load-bearing capabilities. In addition, new prosthetic technologies can be leveraged to create devices that compensate for the fact that the artificial knee joint is lower on one side than the natural joint on the other. “We now hope to send out engineers to countries, including Cambodia, that have many landmine casualties to show them how to design, build, and maintain artificial prostheses [that] can be worn comfortably by people who lose a limb due to this type of blast injury,” said Bull.

PHOTOS: iStock.com/fivepointsix/D3Damon

Individuals with experience of exposure in prosthetics and orthotics are encouraged to take the survey at bit.ly/surveyop.

Trauma surgeons who work with landmine victims in Cambodia, Sri Lanka, and Algeria met in July to discuss best practices in dealing with injuries resulting from landmines. The surgeons suggested rethinking how lower-limb surgical amputations are performed, according to a blog posting by Anthony Bull, head of the department of engineering at Imperial College, London, and director of the Center for Blast Injury Studies. Past guidelines have recommended that necessary amputations for landmine survivors be carried out above the knee joint, with some portion of the lower thigh bone removed also, to eliminate the bulbous lumps of the distal femur. This type of amputation results in a clean residual limb, with enough excess skin remaining to cover the wound, and also results in a rounded stump to aid in prosthetic fitting. These guidelines should be reevalulated, says Bull, due to information gathered treating injured soldiers during the Iraq and Afghan conflicts. “Patients regain better mobility with less pain if they do not have an above-knee amputation, instead of having a through-knee surgery [that] maintains

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HAPPENINGS

O&P ATHLETICS

Limbionics Hosts First Clinic

CODING CORNER

DMEPOS Providers Reminded To Report Changes Within 30 Days information reported on the CMS has published a CMS 855S enrollment form Medlearn Matters article must be reported within reminding Medicare pro30 days of the changes. viders and suppliers of their MLN Matters® Article 2015 Index Reporting these changes responsibility to report any is achieved by completing changes to their provider the relevant sections of file in order to maintain the CMS 855S enrollment Medicare billing privileges. form and returning the For durable medical form to the National equipment, prosthetics, Supplier Clearinghouse. orthotics, and supplies The full Medlearn Matters article (DMEPOS) suppliers, which includes is available at www.CMS.gov. O&P providers, any changes to the DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services

Through July 2016

Limbionics of Durham in North Carolina recently hosted an Orthotic & Prosthetic Activities Foundation (OPAF) First Stride First Things First Training and Clinic at The Brian Center of Durham. The event featured a morning session for therapists and adaptive recreation professionals that covered outcome measures, K levels, and prosthetic feet and knees and their capabilities, as well as a discussion of falls and recovery. More than 35 patients and therapists took part in the afternoon clinic session, held in the workout gym of The Brian Center. The session also featured exercises for strength and conditioning as well as an entire section on falls and recovery.

OCTOBER 2016 | O&P ALMANAC

DME MACs Release New Coding Guidelines The four durable medical equipment Medicare administrative contractors (DME MACs) have released a joint correct coding bulletin reminding DMEPOS suppliers that it is each supplier’s responsibility to select the proper Health-Care Common Procedure Coding System (HCPCS) codes for billing. The full bulletin is available on Noridian’s website. To aid suppliers in their selection of the proper HCPCS codes, the DME MACs offer the following tips: • Check the Pricing, Data Analysis, and Coding (PDAC) Product Classification Lists. • Review DME MAC publications for coding bulletins and coding guidelines. • Refer to the long code descriptor and select the code with the descriptor that most closely describes the item you are providing. • Most code narratives are written broadly to be all inclusive. You may not find a specific code that perfectly matches a product. Use the code

that most closely describes the item rather than a not-otherwiseclassified or miscellaneous code. • Review the Local Coverages of Determination and Policy Articles for coding guidelines for additional information on the characteristics of products that meet a specific HCPCS code. • Don’t select a code based upon the fee schedule amount. HCPCS codes describe the product, not the price. • Check with the PDAC contractor. The PDAC may provide information, outside of a formal product review, that will assist you in code selection. The bulletin also emphasized that the DME MACs and the PDAC are the only entities that have the authority to assign HCPCS codes to specific products. If a supplier chooses to follow coding recommendations from outside sources, those recommendations will have no “official standing” during a possible claim review or audit.

HAPPENINGS

O&P ATHLETICS

INSURANCE INSIGHTS

Insured Pay More in Deductibles U.S. workers are paying significantly more out of their own pockets in deductibles before insurance kicks in, according to the results of a survey conducted by the Kaiser Family Foundation and Health Research & Educational Trust. In 2016, 80 percent of workers had a deductible as part of their individual coverage, averaging $1,478. Deductibles have grown 10 times as fast as inflation and six times as fast as wages over the past five years, according to the Kaiser findings. Half of all workers now have deductibles of at least $1,000 through their employer-sponsored insurance plans—up from 10 percent of workers

in 2006. The average deductible for individuals in firms with fewer than 200 employees is $2,069. “We've been so fixated on the Affordable Care Act, we’ve missed a gradual sea change in what health insurance is for most Americans,” said Drew Altman, president of the Kaiser Family Foundation. The effect of those high deductibles is mediated in some plans by employer contributions to health savings accounts. The proportion of workers facing at least a $1,000 deductible for single coverage drops from 50 percent to 38 percent once the employer contributions are taken into account.

Purdy Performs at Rio Opening Ceremony

Percentage of Workers With Deductible of $1,000 or More 51% 40%

20% 10% 0%

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

SOURCE: Kaiser Family Foundation

THE LIGHTER SIDE

Snowboarder and Parlaympian medalist Amy Purdy performed a five-minute solo performance at Maracana Stadium during the Paralympic Games opening ceremony in September. In a first-of-its-kind performance, Purdy, a bilateral amputee, danced her own version of a samba with KUKA, a self-propelled, industrial robotic arm. Purdy completed her performance wearing running blades and swimming feet from Freedom Innovations. Since the blades were not designed for dancing, Purdy created her own style, relying on core strength during her routine. Her dance was choreographed to demonstrate the “endless energy” of Paralympic athletes, according to the Paralympic Committee. Watch the performance at youtube. com/watch?v=kjdR5GDdwSk.

O&P ALMANAC | OCTOBER 2016

PEOPLE & PLACES PROFESSIONALS ANNOUNCEMENTS AND TRANSITIONS

Tyler Cook, MSPO Phil Hess, MSPO

Nikki Hooks, CO, BEP, FAACPDM

Julie McCulley, MS, ATC/L

Chad Stalter, MSPO, CFo

Ability Prosthetics and Orthotics Inc. is hosting several residents at its locations throughout the East Coast: Tyler Cook, MSPO, is a resident prosthetist/orthotist at Ability’s Frederick, Maryland, patient-care center. Phil Hess, MSPO, is a resident prosthetist/orthotist at Ability’s Mechanicsburg, Pennsylvania, patient-care center. Nikki Hooks, CO, BEP, FAACPDM, regional director at Ability, also is finishing her prosthetics residency at Ability. Julie McCulley, MS, ATC/L, is a resident prosthetist/orthotist at the facility’s Exton, Pennsylvania, patient-care center. Chad Stalter, MSPO, CFo, is a resident prosthetist/orthotist in Ability’s Hanover, Pennsylvania, patient-care center. Mark Muller, CPO, FAAOP, MS, has been named the chair of the department of orthotics and prosthetics at California State University, Dominguez Hills (CSUDH). Muller joined CSUDH in 2006, and is responsible for developing new curricula in gate and biomechanics as well as working to upgrade all course objectives. Prior to CSUDH, Muller worked in private practice in San Diego, served as education manager for Ossur Americas, and taught at Northwestern P&O Center. He is past president of the American Academy of Orthotists and Prosthetists. Muller replaces Scott Hornbeak, CPO, MBA, FAAOP, who had been director of the program since 1994 and was instrumental in the program’s success. Hornbeak will remain on as a senior faculty member.

OCTOBER 2016 | O&P ALMANAC

Claudia Zacharias, MBA, CAE, president and chief executive officer of the Board of Certification/Accreditation (BOC), has been named a 2016 Circle of Excellence Award finalist by Baltimore SmartCEO. The Circle of Excellence Claudia Zacharias, program recognizes the area’s most accomplished MBA, CAE business leaders for their industry impact and market leadership. Zacharias was named a finalist in recognition of her accomplishments at BOC over the past seven years. She will be honored at an event in November and profiled in the November/ December issue of Baltimore SmartCEO magazine.

BUSINESSES ANNOUNCEMENTS AND TRANSITIONS

Ability Prosthetics and Orthotics Inc. and Freedom Innovations LLC have formed a clinical research partnership to study Freedom’s Kinnex™ microprocessor ankle. The study will compare the benefits of a new microprocessor prosthetic ankle-foot to a typical carbon-fiber prosthetic ankle-foot. The independent study will be executed through a research protocol involving 30 patients, each with three research visits where standardized surveys, functional tests, and two-dimensional motion analysis will be used to investigate how each ankle-foot system impacts mobility, balance, comfort, and walking on sloped surfaces. Össur has acquired Medi Prosthetics from Medi, effective Sept. 1, 2016. Medi Prosthetics is a global provider of mechanical lower-limb prosthetic components, located in Bayreuth, Germany. The integration of the business is expected to be concluded in 2017. Jon Sigurdsson, president and chief executive officer of Össur, said, “We are pleased to welcome the employees of Medi Prosthetics to the Össur team. This acquisition enables us to take another step to complete our prosthetics offering and further strengthen our global market position.” PEL LLC has partnered with Amoena, a breast care brand. PEL began distributing the Amoena product line in August through PEL’s O&P network of providers. Amoena’s apparel line, which includes bras, swimwear, and symmetry products, has been developed for women recovering from a mastectomy or breast reconstruction as well as women experiencing symmetry issues.

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REIMBURSEMENT PAGE

By JOSEPH MCTERNAN

Making the Most of Inpatient Billing Ensuring reimbursement for patients in hospitals, rehab facilities, and skilled nursing facilities 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 20 to take the Reimbursement Page quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.

OCTOBER 2016 | O&P ALMANAC

ETERMINING WHO SHOULD

be billed for inpatient services provided to Medicare beneficiaries can get complicated. Administrators and providers may become confused regarding who is responsible for paying for O&P services that are needed during an inpatient admission. This month’s Reimbursement Page discusses some of the common scenarios you may encounter and explains who is ultimately responsible for paying for the O&P services you provide. The location where an orthosis or prosthesis will be used is usually what determines who is responsible for paying the claim. In most cases, a Medicare beneficiary will come to your office to receive an orthotic or prosthetic device and subsequently use the completed device in his or her home. In this scenario, the rules are simple: Your claim should list the place of service as 12 (home) and should be submitted to the appropriate durable medical equipment Medicare administrative contractor (DME MAC). Sometimes, however, you will treat a patient during a hospital, rehab facility, or Medicare Part A covered skilled nursing facility (SNF) stay. Usually, when this occurs, you may not submit your claim to the DME MAC. Acute care hospitals, rehab hospitals, and SNFs are paid for Medicare Part A services through a prospective payment system (PPS). This system pays the facility a daily rate to cover the cost of all medically necessary services required by the patient during his or her inpatient admission. The payment is the same whether the hospital or SNF pays for the services through its own internal

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resources or through a vendor relationship with an outside provider. When a hospital or SNF is unable to provide a service, it will use outside suppliers to provide the service. The facility then must pay the outside supplier for the services, since the facility has already received payment in full for the patient’s care under the PPS. The hospital or SNF has the right to choose the vendor of its choice in this situation, and it is recommended that the payment terms be agreed upon prior to providing service to its patients. While the two situations discussed above account for the majority of O&P billing scenarios, there are several important exceptions that may result in a need to submit your claim differently. The Two-Day Rule One exception to the general rule for billing the hospital or SNF is the “two-day rule.” The two-day rule states that a supplier may deliver a completed O&P device to a Medicare beneficiary during a Part A hospital or SNF stay within 48 hours (two days) of the patient’s anticipated discharge. As long as the device is not medically necessary during the remainder of the patient’s stay, and that patient is being discharged to a location that qualifies as his or her home, the supplier may bill the DME MAC directly for the device. However, the supplier must only be delivering the item in order to provide basic instruction on how to use and care for the device. The intent of the two-day rule is not to circumvent the responsibility of the hospital or SNF to provide its patients with medically necessary services. If an O&P device is

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E! QU IZ M

REIMBURSEMENT PAGE

PHOTO:iStock.com/Arpad Benedek

needed as part of the patient’s recovery or rehabilitation in the facility, it must be paid for by the facility regardless of when it was delivered. O&P providers must be especially aware of this requirement as many inpatient facilities try to utilize the two-day rule to avoid having to pay for medically necessary items provided to patients who are under their care. If you deliver an O&P device to a patient during a Medicare Part A hospital or SNF stay and all of the criteria to bill under the two-day rule have been met, the claim may be submitted to the DME MAC following these guidelines: Date of service. Under normal billing circumstances, the date of service is usually the date that the completed device is delivered. However, when submitting a claim under the two-day rule, the date of service is the patient’s discharge date from the inpatient facility. Without this exception, the DME MAC would improperly deny the claim as the responsibility of the inpatient facility. While the two-day rule allows you to use the date of discharge as your date

of service, the actual date of delivery should be documented in the patient’s chart in case there are questions later on. Place of service. Generally, the code selected should correspond with the location where the item will be used. This holds true under the two-day rule. When billing under this rule, indicate a place of service code of 12 (home).

Exhaustion of SNF Part A Benefits

Medicare limits the number of days for which it will cover Part A SNF services to 100 days per benefit period. A new benefit period begins with a mandatory hospital admission of at least three days

followed by immediate admission to the SNF. As long as a minimum of 60 consecutive days have passed since the patient was last in a Medicare Part A SNF stay, a new benefit period may begin, staring with day 1. If a Medicare patient is in a Medicare Part A SNF stay for less than 100 days and is discharged, he or she remains eligible for the remaining days in the benefit period. For example, if a patient is in the hospital for hip replacement surgery and is discharged to an SNF where he or she stays for 30 days, that patient has 70 days of Medicare Part A coverage remaining for that benefit period. If after two weeks at home, additional SNF care is needed, the patient can be readmitted to the SNF (without an additional hospital stay) and receive another 70 days of Medicare Part A SNF coverage. After 100 days of Medicare Part A SNF coverage within a benefit period, Medicare Part A no longer covers the SNF stay. If the patient remains in the SNF, he or she must pay for room, board, and nursing

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O&P ALMANAC | OCTOBER 2016

expenses through personal funds or other insurance. Medicare Part B will cover any orthotic and prosthetic care that the patient needs. When this is the case, you may submit your claim directly to the DME MAC for consideration. Remember that 100 days is the Medicare Part A benefit limit and not an entitlement. In order for Medicare Part A to continue covering SNF care, the patient must continue to progress through therapy. Patients must be evaluated on a regular basis by the SNF staff. If the patient fails to progress, Medicare Part A will no longer cover the SNF stay, and you may submit your claim to the DME MAC. When determining whether the patient is in a Medicare Part A SNF stay, you should confirm the patient’s status with the facility business office. While therapists and physicians may provide you with limited information, the business office should provide a definitive Medicare status of any patient at any given time. Getting this information in writing for inclusion in your files may help if there is future confusion regarding who is responsible for payment.

SNF Prosthetic Device Exceptions

OCTOBER 2016 | O&P ALMANAC

Transferring From Hospital or Home to SNF

Another exception to regular billing rules occurs when a patient is being transferred from a hospital to an SNF. If a custom-fabricated O&P device is ordered for the patient while he or she is still in the hospital, but due to fabrication

Joe McTernan is director of reimbursement services at AOPA. Reach him at jmcternan@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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As discussed above, SNFs receive a per diem PPS payment to provide all medically necessary care for patients in a Medicare covered Part A stay. Beginning in April 2000, however, most prosthetic devices were excluded from the SNF PPS system, because the high cost and relatively low volume of prosthetic services provided in SNF settings had

resulted in an undue financial burden on SNFs. Excluding most prosthetic devices from the PPS allowed suppliers to bill their DME MAC directly, instead of looking to the SNF for payment. While most prosthetic services have been excluded from the SNF PPS system, certain services, such as prosthetic socks, shrinkers, partial hand and partial feet prostheses, and immediate postsurgical prostheses, continue to be included in the SNF PPS payment. In addition, one prosthetic foot code, L5987, is not included in the PPS exemption list. These items, as well as all orthoses, must be paid for by the SNF when a patient is in a Medicare Part A covered stay. A list of codes excluded from the SNF PPS can be found at www.cms.gov/Medicare/Billing/ SNFConsolidatedBilling/2016-PartB-MAC-Update.html. Once at this page, scroll down to “Downloads” and select File 1—Part A Stay—Physician Services. (Although the file says “Physician Services,” this list is still applicable to O&P suppliers.) The list of exempt L codes begins about halfway through the file. If a particular L code does not appear on this list, it is not exempt and you must make payment arrangements with the SNF.

time, it is not delivered until after she arrives at the SNF, the hospital remains responsible for payment for the item. Medical necessity for the custom device was established while the patient was in the hospital, not in the SNF, so the SNF should not be billed. The two-day rule would not apply in this particular scenario, either, because the patient is not being discharged to his or her home. Likewise, if the medical necessity for a custom device occurs while the patient is at home, but delivery does not occur until after a Medicare Part A SNF admission, the item may be billed to the DME MAC using the date the medical necessity was established as the date of service and a place of service of 12. Remember that when a hospital or SNF requires the services of an outside supplier for items subject to the Medicare Part A PPS system, it is the facility’s responsibility to make arrangements with the outside supplier. It is always in your best interest to negotiate the terms of your payment prior to delivering your services. While the absence of a contractual agreement does not in any way relieve the facility from its responsibility to pay for such items, making such an agreement prior to providing services will help avoid misunderstandings. Knowing who should be billed, and under what circumstances, is very important for all Medicare suppliers. Your time, costly materials, and hard work are extremely valuable and deserve to be compensated. Arming yourself with this information will help eliminate confusion and ensure proper reimbursement.

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This Just In

AOPA Urges Recoupment Delay Until ALJ Rules Fair and impartial decisions are needed on claims appeals adjudicated through the OMHA process

RTHOTIC AND PROSTHETIC (O&P)

OCTOBER 2016 | O&P ALMANAC

3. Proposing legislative reforms that provide additional funding and new authorities to address the appeals volume. A proposed rule to address the delay issue was published in the July 5, 2016, issue of the Federal Register, and AOPA submitted comments by the Aug. 29, 2016, deadline. View the comments at bit.ly/omhacomments. In summary, AOPA commended the agency for taking steps to deal with the issue but took exception to some of the details in the proposal—chief among them, the removal of the word “must” from the regulatory language 42 C.F.R. 401.1106(a). Removal of the word “must” violates the statutory language, which is clear that decisions “must be issued by the ALJ within 90 days of the appeal of a decision issued by a qualified independent contractor.” Another provision authorizing the chair of the Departmental Appeals Board to declare certain decisions of the Medicare Appeals Council precedential for application to future cases also may help reduce the backlog. AOPA did express concern that the rule lacked specificity on criteria to determine whether a decision is precedential and

PHOTO:iStock.com/Infografx

providers have been bedeviled by the harsh recoupment policies followed by CMS and the recovery audit contractors (RACs), especially in light of the three- to four-year delay in setting hearing dates for appeals reaching the administrative law judge (ALJ) level. The statutory requirement that ALJs render decisions within 90 days of receiving a claims appeal has been breached for several years—since the “Dear Physician Letter” basically changed the entire reimbursement picture for O&P and RAC audit recoupments crippled provider cash flows. AOPA has consistently urged the U.S. Department of Health and Human Services (HHS) and the Office of Medicare Hearings and Appeals (OMHA) to resolve the problem. In response, OMHA has articulated a plan of action that includes the following: 1. Investing in new resources at all levels of appeal to increase adjudication capacity and implement new strategies to alleviate the current backlog. 2. Taking administrative actions to reduce the number of pending appeals and encourage resolution of cases earlier in the process.

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AOPA Coding Experts Are Coming to Las Vegas 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 O&P practitioners and billing staff. The seminar features hands-on breakout sessions, where you will practice coding complex devices, including repairs and adjustments. Breakouts are tailored specifically for practitioners and billing staff. Take part in this seminar and better your business, your staff, and your patients! Don’t miss the opportunity to experience two jam-packed days of valuable O&P coding and billing information. Learn more and see the rest of the year’s schedule at bit.ly/2016billing. In this audit-heavy climate, can you afford not to attend?

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This Just In

the lack of any guidance on timeframes for the chair’s decision. Also lacking was a pathway to challenge a precedential determination. The proposed rule would create nonjudicial (attorney) adjudicators to help reduce the backlog, which is a plus. However, AOPA pointed out that the appellant’s consent to an attorney adjudicator rather than an ALJ is needed. The final rule also must clearly outline required qualifications for the attorney adjudicators as well as the types of cases for which they will be allowed to render decisions. AOPA supported another proposed change that would allow for the consolidation of similar claims into a single hearing and decision, saving appellants and OMHA valuable time by eliminating duplicative and redundant hearings. AOPA’s comments also recommended that the final rule allow for the rescheduling of an ALJ hearing when the appellant’s witnesses are

unavailable to provide testimony due to direct patient-care duties. The most important AOPA recommendation was that the final rule contain provisions that prevent the recoupment of funds for services that remain under appeal until an ALJ decision has been rendered. That recommendation is consistent with legislative language AOPA has advocated for in pending pieces of legislation in the House of Representatives. In general comments, AOPA said, “While AOPA supports the OMHA efforts to take necessary action to reduce the backlog of pending hearing requests, there must be reasonable assurances that any regulatory action that is taken to accomplish this goal does not compromise, in any way, the right to a fair and impartial decision on claim appeals that are adjudicated through the OMHA process.” In a related development, U.S. District Court Judge Boasberg

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rejected a request from HHS for a one-year delay in responding to a lawsuit filed by the American Hospital Association (AHA) seeking relief from the burdens imposed by RAC audits resulting from the now four-year delay in scheduling appeals at the ALJ level. HHS cited proposed regulations intended to “fix” the problem as a solution to the AHA complaint. Boasberg concluded the proposed regulations were unlikely to provide relief and the lawsuit should proceed. In a “Breaking News” email to members, AOPA pointed out that commission-paid RAC auditors plus HHS interest payment obligations on any recoupments subsequently overturned over four years could bring additional costs of 50 percent or more to the U.S. Department of the Treasury for any denied claims won on appeal. A Dobson-DaVanzo study showed 58 percent of O&P RAC appeals are won at the ALJ level.

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O&P ALMANAC | OCTOBER 2016

COVER STORY

Smart STAFFING By CHRISTINE UMBRELL

O&P facilities are hiring care extenders with clearly defined job responsibilities to enhance the patient-care experience and improve business efficiencies

NEED TO KNOW • Care extenders such as assistants, technicians, and fitters are a more common presence at O&P facilities as savvy business owners seek to optimize the use and effectiveness of their resources in an increasingly demanding reimbursement environment. • Facilities must ensure that all care is provided under the supervision of an orthotist or prosthetist certified by the American Board for Certification in Orthotics, Prosthetics, and Pedorthics (ABC) or the Board of Certification/Accrediation, and is provided in accordance with any Medicare guidelines and state licensure laws that may apply. • The care extender model is a more collaborative approach to patient care, say some O&P clinicians, facilitating discussion among the clinician and other care givers in a “case study” approach to optimal patient care.

• Hiring care extenders may lead to more staff involvement in gathering data to support the efficacy of O&P intervention—which will help elevate the O&P profession in the eyes of other health-care professions as well as payors. 26

OCTOBER 2016 | O&P ALMANAC

PHOTO:iStock.com/Jirsak

• The certified O&P assistant position stands out as a significant area of growth, with increasing numbers achieving certification by ABC and educational institutions adding programming in this area.

COVER STORY

CROSS HEALTH-CARE SECTORS,

care extenders are joining medical facilities at an ever-increasing rate. Physician assistants are climbing the ranks in an annual list of health-care professionals in most demand, according to a 2016 report by Medicus Firm. Nurse practitioners are increasingly common at typical family and pediatric practices. Not to be left out, assistants and aides are playing more visible roles in many physical therapy (PT) offices. The O&P profession is following suit, with care extenders becoming the norm at many facilities. Although the importance of all care being provided under the supervision of an orthotist or prosthetist certified by the American Board for Certification in Orthotics, Prosthetics, and Pedorthics (ABC) or the Board of Certification/ Accreditation (BOC) cannot be overstated, these care extenders are contributing to a more profitable and efficient patient-care treatment model, say some clinicians. “To succeed in today’s competitive health-care environment, we need to excel. To excel, O&P practices need to focus on all parts of their organization;

"Clinical assistants or extenders are playing an increasing role not only in the delivery of care but also the ongoing nurturing of patient relationships to enhance operational workflows and overall performance.” PHOTO: iStock.com/Horsche

—James H. Campbell, PhD, CO, FAAOP

“We need to look at certified fitters, certified technicians, and others who have been privileged to provide care, with appropriate CP and CO supervision, in a particular category.” —Pam Lupo, CO

this includes optimizing the use and effectiveness of all of its resources, including clinical staff,” says James H. Campbell, PhD, CO, FAAOP, chief clinical officer at Hanger Clinic and AOPA president. “Clinical assistants or extenders are playing an increasing role not only in the delivery of care but also the ongoing nurturing of patient relationships to enhance operational workflows and overall performance.” “As reimbursement decreases and the O&P community faces changes in policies and adjustments, we need to use care extenders when possible and appropriate,” says Pam Lupo, CO, a consultant and member of the boards of directors of Wright & Filippis and Carolina Orthotics & Prosthetics. “We need to look at certified fitters, certified technicians, and others who have been privileged to provide care, with appropriate CP and CO supervision, in a particular category.” The rise in the use of care extenders can be partially attributed to O&P facilities becoming more business savvy in the increasingly demanding reimbursement environment, says Charles Kuffel, MSM, CPO, FAAOP, president and clinical director for Arise Orthotics & Prosthetics Inc. and chair of the National Commission on Orthotic and Prosthetic Education (NCOPE). “It really comes down to economics. You can be a good clinician, but if you don’t understand the business aspects, you won’t be successful.”

prosthetist, certified O&P assistant, certified orthotic fitter, and/or certified technician. While the certified orthotist or prosthetist must oversee all care and perform some of the higher-level patient-care tasks, other aspects of care are carried out by the rest of the team, in accordance with the scopes of practice defined by the certifying bodies. Adhering to state licensure laws, which vary from state to state, also is important when assigning responsibilities to various care extenders, says Lupo. At Carolina Orthotics & Prosthetics, care extenders have played a significant role ever since management took a closer look at “practitioner time versus care extender time,” a couple of years ago, says C. Ralph Hooper Jr., CPO, the company’s president. Today, Carolina O&P uses assistants and fitters extensively, under the supervision of certified practitioners and in compliance with

A Team Approach

The care extender model is a more collaborative approach to patient care because patients may be seen by a team comprised of a certified orthotist or O&P ALMANAC | OCTOBER 2016

COVER STORY

Categories of

Care Extenders THERAPEUTIC SHOE FITTER A therapeutic shoe fitter is trained to provide non-custom therapeutic shoes and non-custom multidensity diabetic inserts. ABC currently offers certification of therapeutic shoe fitters, and details about the scope of practice as defined by ABC are available on the ABC website.

A mastectomy fitter provides and/or supervises the provision of external breast prostheses and postmastectomy items and services. Both ABC and BOC offer certification of mastectomy fitters, and details about scope of practice are available on the websites of both ABC and BOC.

MASTECTOMY FITTER

Medicare guidelines. “Assistants can do measurements, preliminary fittings, and adjustments, with clinicians checking their work,” says Hooper. Scheck & Siress also participated in a time study three years ago, tracking, in each device category, how many practitioners were truly spending their time “up to their credential,” says Michael Oros, CPO, FAAOP, the company’s president and chief executive officer and incoming AOPA president. For example, management studied whether CPOs were concentrating their efforts on fitting custom-fabricated devices, rather than repair work or off-the-shelf devices. During the study, Oros found that between 20 and 25 percent of some practitioners’ time was spent 28

OCTOBER 2016 | O&P ALMANAC

O&P ASSISTANT An orthotic/prosthetic assistant supports a certified practitioner in providing comprehensive O&P patient care. Under the guidance and supervision of certified practitioners, certified assistants may perform orthotic and/or prosthetic procedures and related tasks in the management of patients. The American Board for Certification in Orthotics, Prosthetics, and Pedorthics (ABC) currently offers certification of assistants, and the National Commission on Orthotic and Prosthetic Education (NCOPE) is preparing standards for this position, to be released in early 2017. Details about the scope of practice as defined by ABC are available on the ABC website.

O&P facilities may staff their facilities with a variety of care extender positions, including the following:

ORTHOTIC FITTER An orthotic fitter is involved in providing certain prefabricated orthoses. Both ABC and the Board of Certification/ Accreditation (BOC) offer certification of orthotic fitters, and details about scope of practice are available on the websites of both ABC and BOC.

TECHNICIAN A technician supports a certified practitioner’s provision of comprehensive O&P patient care and may be involved in fabrication, repairs, and maintenance of devices. ABC currently offers certification of technicians, and details about the scope of practice as defined by ABC are available on the ABC website.

C. Ralph Hooper Jr., CPO

doing “non-max-value” activities— tasks that could be completed by lower-credentialed staff, with lower compensation levels. Today, each Scheck & Siress facility has a balance of certified orthotists/ prosthetists and care extenders on staff. For example, a typical facility may staff two or three certified practitioners, one certified fitter, one certified pedorthist, and one certified assistant, says Oros.

When determining which staff member will see particular patients, Oros says his managers “look at scope of practice” as defined by ABC and assign duties accordingly. Fitters can act more independently than other care extenders, seeing patients who need both custom-fit and off-the-shelf O&P devices as long as they work within the scope of practice, says Oros. While the certified orthotist or prosthetist remains responsible for the initial assessment, supervision, and final approval of a device, “assistants can meet some of the administrative and clinical demands of certified practitioners, and can help with functional outcome assessments” before and after a new device has been fit.

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COVER STORY

“Assistants help de-burden certified practitioners” by aiding with taking

CSUDH To Add ‘Extender’ Education California State University, Dominguez Hills (CSUDH), has announced a three-year plan to offer O&P education for “a few new pathways, which will include an assistant level as well as other new programs,” says Mark Muller, CPO, FAAOP, MS, chair of the O&P department. The first level will involve the creation of a 12-week certificate in additive manufacturing for medical devices where technicians, assistants, or practitioners can learn more about graphic design, computer-aided design, 3D printing, and other forms of additive manufacturing. CSUDH also will offer a 24-30 credit unit certificate for an orthotic and prosthetic assistant. “This certificate can be a standalone certification where the individual would meet all of the requirements for an O&P assistant and can begin practicing under the supervision of a certified practitioner; or the certification can be implemented into a bachelor’s degree track in kinesiology,” says Muller. “If the student wishes to pursue a bachelor’s degree, the O&P assistant certificate would be combined with courses in kinesiology, anatomy, psychology, and basic sciences, so they could earn a bachelor’s of science degree.” The bachelor’s degree could be used as a stepping stone for CSUDH’s master’s of science in orthotics and prosthetics program. “We are focusing great time and effort into creating these tracks, so we can have all aspects of our profession represented, which in turn will afford us the opportunity to grow as a recognized profession,” says Muller. “Our vision at CSUDH is to create a complete multilevel education center for O&P that will not only include training for practitioners but for care extenders as well,” he says. “We will create multiple education pathways, so more qualified individuals can enter into our great profession.”

OCTOBER 2016 | O&P ALMANAC

patients’ vitals, performing diagnostic tasks, gathering qualitative and quantitative data, and providing general support to clinicians. —Charles Kuffel, MSM, CPO, FAAOP

The more frequent use of O&P care extenders “improves patient care” because it promotes a more collaborative approach to treatment decisions, says Kuffel. “It’s no longer left to just one person’s decision-making abilities—there is more involvement and discussion of each case” among the care extenders involved with each patient, and each patient benefits from a “case study” approach to optimal patient care. With a care extender staffing model, certified orthotists and prosthetists are able to see more patients each day. With that, “there are expectations of productivity for each CP or CO. If we add an assistant to the mix, your facility’s CO and CP metrics should demonstrate that the assistant is adding value,” says Oros. Care extenders are used at Hanger Clinic when it is appropriate for patient care, says Campbell. “The design and implementation of patient engagement strategies and clinical operational protocols and standards are designed to help us identify best practice,” he says. “In our best practice model, our clinicians maintain a clear clinical focus; in some cases, this can be achieved by the appropriate use of support staff, including technicians, fitters, assistants, and administrative staff.”

O&P ALMANAC | OCTOBER 2016

COVER STORY

"Assistants can meet some of the administrative and clinical demands of certified practitioners, and can help with functional outcome assessments.” —Michael Oros, CPO, FAAOP

Of course, even in a team approach, the role of the certified orthotist or prosthetist continues to be paramount, says Campbell. “The certified clinician retains responsibility for the management of the patient; the role of the assistant or fitter is not to substitute or replace the clinician; it is to augment and extend through education and counseling, as well as communication with providers,” he says. “Their patient-facing positions are what make them a key role in the changing healthcare landscape.”

The Rise of the O&P Assistant

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In fact, California State University, Dominguez Hills (CSUDH), recently announced programming for the O&P assistant position as part of its three-year plan to provide increased education for O&P care extenders (see sidebar, “CSUDH To Add ‘Extender’ Education”). “We see the assistant’s role as a large part of this vision, where they would implement many of the outcome measures, make the client comfortable, intake basic assessment measures, assist with non-custom device implementation, and free up the practitioner to focus on creating the best treatment plan for each person,” says Mark Muller, CPO, FAAOP, MS, chair of the CSUDH O&P department. Kuffel says that as more assistants become available, and more facilities recognize the business advantages of employing these staff members, O&P

PHOTO: Top left, iStock.com/ Horsche, lower right, iStock.com/diego_cervo

As more facilities consider employing more care extenders, the certified O&P assistant position stands out as a significant area of growth. With the recent addition of the educational requirement of a master’s degree for CPOs came an opportunity for those with less education to take on other important roles, says Oros. In 2005 and 2010, there were approximately 125 assistants certified by ABC; in 2015, that number had jumped to 868, according to Debbie Ayres, director of marketing and public relations for ABC. Currently, ABC certifies O&P assistants to perform “orthotic and/or prosthetic procedures and related tasks in

the management of patients. This includes fabrication, repairs, and maintenance of devices to provide maximum fit, function, and cosmesis that reflect the level of education and training received,” according to ABC’s website. These assistants “may not use their credential as independent practitioners engaged in unsupervised patient care.” The initial evaluation and formulation of the treatment plan is the responsibility of the supervising orthotist and/or prosthetist. With the rise in popularity of the O&P assistant role, NCOPE is in the process of developing standards for that position, which will be introduced early next year, says Kuffel. The standards will ensure that the assistant position is treated equivalently throughout O&P facilities and is responsible for only those duties for which the individual is hired to work. “There is a lot of interest in the assistant position since it only requires an associate’s degree,” says Kuffel. “Assistants help de-burden certified practitioners” by aiding with taking patients’ vitals, performing diagnostic tasks, gathering qualitative and quantitative data, and providing general support to clinicians. “With the increased burden of Medicare and Medicaid requirements, certified clinicians don’t have enough time to do all of the things that are required of us and still be profitable,” says Kuffel. He predicts that more educational institutions will offer coursework geared toward the O&P assistant once the standards are in place.

COVER STORY

facilities may see similarities to the staffing structures at typical PT offices, where a doctor of physical therapy (DPT) works with three or four assistant PTs on staff. And Hooper notes that O&P assistants are being used in much the same way physician practices are using physician assistants today—“and they are getting credibility for what they’re doing,” he says.

A Variety of Care Extenders

In addition to certified assistants, some O&P facilities are employing other care extenders to supplement their staff. Orthotic fitters and mastectomy fitters remain in demand: Both BOC and ABC continue to have hundreds of new certificants in these categories each year. In fact, more than 600 technicians were certified in good standing with ABC in 2015. Another opportunity for the use of care extenders is with a certified therapeutic shoe fitter. This position may provide non-custom therapeutic shoes and non-custom multidensity inserts, including fitting, adjusting, or modifying these devices. “We’ve seen the value of the certified therapeutic shoe fitter credential,” says Oros. “In the absence of a CPed on staff, there can be a place for a therapeutic shoe fitter, working with the CO.” He notes that facilities with a significant wound management or diabetic foot care population may benefit from staffing these individuals. Of course, it’s important to ensure that certified shoe fitters—and any other types of care extenders—are providing only those services for which they are qualified, says Kuffel. “We can’t allow extenders to work outside of their scope of practice,” he says. PHOTO: iStock.com/Christopher Futcher

Focus on the Future

A significant byproduct of the increased use of assistants and other care extenders is more staff involvement in gathering data to support the efficacy of O&P intervention—which will help elevate the O&P profession in the eyes of other health-care professions, as well as payors.

“The rapid drive toward cost-efficient, evidence-based, and outcome-driven O&P care is not slowing down. To collect outcomes and provide comprehensive high-quality care, we must have trained people with varying skillsets,” says Campbell. “We must all defend and articulate the critical and essential role played by the certified orthotic and prosthetic clinician in the delivery of O&P care. However, creating a balanced and diversified staff with varying skills sets can strengthen the role and increase the efficiency of the certified clinician.” CSUDH’s Muller also predicts the care extender model will play a critical role in advancing the profession. “The need for evidence-based medicine, positive outcome measures, and a better understanding of the emotional well-being of the people we serve requires unique skills, time, and dedication,” he says. “The use of care extenders can help our certified practitioners spend more time with our clients to better understand their needs and better understand how to best prove that the intervention they created will be beneficial for the user.” Overall, Kuffel believes the increased use of care extenders will

help to more accurately define and even elevate the O&P profession in the eyes of other health-care stakeholders. “The profession is driving into a much more streamlined process, where an MSPO-educated clinician might oversee assistants and technicians, all focusing on O&P care.” This transition “lifts our validity in the minds of medical professionals.” It’s clear that O&P businesses are getting smarter in their staffing decisions. As care extenders play an increasingly important role in O&P, consistency of care will remain a driving factor in successful businesses, says Campbell. “The care must be coordinated and patient-centered irrespective of who the patient is interacting with,” he says. “There is a linear relationship between clinical quality and patient satisfaction, or the ‘patient experience.’ Patients deserve to be treated with kindness, compassion, and concern, and receive a device in a timely and responsive manner, that enhances and improves their lives.” Christine Umbrell is a staff writer and editorial/production associate for O&P Almanac. Reach her at cumbrell@contentcommunicators.com. O&P ALMANAC | OCTOBER 2016

By CHRISTINE UMBRELL

An HONOR to

SERVE

How professionals provide optimal O&P care not only to combat-injured service members but also aging veterans

NEED TO KNOW While some O&P professionals work diligently to treat those U.S. service members injured in the most recent conflicts, prosthetists and orthotists also are called upon to treat older veterans who present with diabetes, vascular disease, and other medical conditions. Itâ&#x20AC;&#x2122;s important to consider patient preferences when selecting componentry. While advanced electronic devices may be appropriate for some veteran amputees, other long-time amputees may prefer more traditional systems. Clinicians should take a collaborative approach to patient care when treating veterans, and educate patients about support groups and adaptive sports programs that may be available locally. Research programs are in place at U.S. medical centers to study optimal treatment protocols. At Walter Reed National Military Medical Center, current research is focusing on advanced rehabilitation sciences; orthotics and prosthetics; and medical/surgical interventions. 34

OCTOBER 2016 | O&P ALMANAC

VER THE COURSE OF U.S. history, pros-

thetic innovation has been driven in many cases by a need to provide high-quality care for those who have lost limbs while serving in the armed forces. All of the major conflicts of the past century have resulted in thousands of major amputations: 2,300 during World War I; 18,000 during World War II; 1,500 during the Korean War; and 5,300 during the Vietnam War, according to data from the Veterans Health Initiative and VFW Magazine. Throughout the years, military medical centers, the U.S. Department of Veterans Affairs (VA), and some private facilities have been called upon to provide O&P care to return service members to a quality of life they deserve after sacrificing their health to protect our nation. Optimal O&P treatment does not stop once a new amputee receives his or her prosthesis. Our veterans require ongoing care throughout

PHOTO: Hanger Clinic

their lives—and many veterans who were not injured in battle eventually require orthotic or prosthetic intervention as they age. Understanding how to provide appropriate care for those individuals who were willing to give their lives for our country—no matter their age—is important for O&P professionals. Frank Snell, CPO, FAAOP, president of Snell Prosthetic & Orthotic (P&O) Laboratory in Arkansas and a greatnephew of the facility’s founder, has worked with hundreds of veterans. During his 44-year career, he has treated veterans of World War I, World War II, Korea, Vietnam, and the Middle East conflicts. Snell P&O has had a contract with the VA for more than 50 years, and Snell has attended the same VA clinic for the duration of his career. In his experience, “the VA has always been on the leading edge of research and development as a result of our wars,” says Snell, who also chairs AOPA’s VA Committee. “A lot of our hydraulic knees and upperlimb componentry came out of World War II, and the Vietnam War led to the development of specialized care centers for returning vets. “A lot of what we’re able to do with the non-VA population is because the VA chooses to do it with veterans,” says Snell. He cites the example of microprocessor knees, which the VA began covering soon after their development, in the 2002-2003 timeframe. “As the newer-technology knees were accepted by the VA as being a proper application of technology, many other third-party payors, including Medicare, adopted them into their approved coding system for payment,” he says. Today, Snell sees a large contingent of Vietnam veterans, as well as some VA patients who were not injured in battle but who require O&P care due to vascular or diabetes-related issues. “While new amputees are seen and treated by the local VA prosthetic lab, in many instances the veterans are allowed to experience community-based care closer to their homes,” says Snell.

Bill Dunham, area clinic manager–Oklahoma for Hanger Clinic, with retired service member Josh Wells

Generational Gaps

While some of the older veterans who require prostheses are intrigued by the newest technologies, others seem satisfied with more traditional devices. “Vietnam vets have been amputees for a very long time and have been functioning at a very high level using older technologies,” says Dennis Clark, CPO, founder and partner at Limb Lab, president of Clark and Associates Prosthetics and Orthotics, and president of Orthotic and Prosthetic Group of America. His facility sees both service-connected and nonservice-connected VA patients in conjunction with a VA contract. Clark explains that when older veterans are given the opportunity to update their componentry to more high-tech devices, “most want to stick with what they have and don’t necessarily want to learn to use new devices.”

Frank Snell, CPO, FAAOP

O&P ALMANAC | OCTOBER 2016

OCTOBER 2016 | O&P ALMANAC

Yet there is a contingent of older veterans who do enjoy testing componentry that would have been unimaginable 40 years ago: “Some of these vets are being fit with microprocessor devices, ultralight componentry, and other new technologies that weren’t available when they were discharged,” says Snell.

Treating Aging Veterans

Due to their age, Vietnam veterans—whether injured in battle or previously healthy—are beginning to require additional health care. “All of the health issues we always see in the aging population are happening with Vietnam vets—but in many cases, their issues are more advanced due to the long-term wear-and-tear their bodies have experienced,” says Snell. In addition to vascular disease or diabetes, many of these vets are presenting with arthritis in their sound limbs, a number of co-morbidities, and even an increased incidence of cancer, possibly caused by exposure to Agent Orange, says Snell. “As we age, issues can accrue—such as diabetes, vascular disease, and stroke—which may lead to a veteran needing help from an orthotist or prosthetist,” says Kevin Carroll, MS, CP, FAAOP, vice president of prosthetics for Hanger Clinic. (Continued on page 41)

PHOTOS: Hanger Clinic

Clark’s observations are supported by a study focusing on preference and satisfaction levels of amputees of the Vietnam War versus those from the Middle East conflicts. In “CombatIncurred Bilateral Transfemoral Limb Loss: A Comparison of the Vietnam War to the Wars in Afghanistan and Iraq,” researchers from the University of Michigan, the University of Washington, and the VA transfemoral limb loss were identified amputees from remarkably similar for the the VA databases, then two conflict groups in regard surveyed 298 participants to nature of injuries and from the Vietnam conflict reported quality of life, but and 283 from the Iraq/ showed significant differAfghanistan conflicts in ences in prosthetic use and 2012. Both groups were levels of function.” Dennis Clark, CPO similar in the distribuThe Vietnam vets “are tion of gender and type now in their 60s and 70s, and of amputation; however, there were are a little more set in their ways,” says more Vietnam participants who had Clark, “so it’s logical that they may not sustained multiple limb losses. perceive that they need new technolThe study’s key findings include the ogies—they’re not a part of today’s following: society that always needs the ‘latest • Among the participants, bilateral and greatest,’ and they also may be transfemoral limb loss was more concerned about the expense of new common for the Vietnam veterans devices, and may not want to burden (23 of 298 surveyed, or 7.7 percent) the VA system with expensive new compared with the Iraq/Afghanistan components. veterans (10 of 283 surveyed, or “We’ve all had opportunities to talk 3.5 percent). with vets who have older suspension • Only 17 percent of the Vietnam systems and offer them newer systems, veterans were using advanced but often they are happy with what ‘‘electronic’’ prostheses, while 60 they have,” says Clark. percent of the Iraq/Afghanistan group reported using at least one electronic device. • Regardless of the type of prostheses used, the average level of prosthetic satisfaction was statistically similar for the Vietnam and Iraq/ Afghanistan participants who used prostheses: “I am satisfied with my prosthesis,” was reported by 100 percent of the Vietnam Kevin Carroll, group and 85.7 percent of the MS, CP, FAAOP Iraq/Afghanistan group. The researchers concluded that the “service members with bilateral

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Q&A

With Walter Reed National Military Medical Center

The Walter Reed National Military Medical Center (WRNMMC) in Bethesda, Maryland, is one of the most well-known U.S. medical facilities to treat injured service members. WRNMMC comprises nearly 7,000 staff members who provide treatment for military families and the nation’s active-duty service members, returning war heroes, veterans, and U.S. leaders. The 2.4 million-square-foot facility provides care and services to more than one million beneficiaries each year. O&P Almanac reached out to WRNMMC to learn about O&P treatment methodologies, long-term care, and current research that may benefit the O&P community. Several subject matter experts offered their responses.

O&P Almanac: Given that the population of service members wounded in conflict is generally young males, what should orthotists and prosthetists know about long-term care for this population?

O&P Almanac: If a service member is injured on duty and requires prosthetic/orthotic care, what should O&P professionals keep in mind to ensure overall long-term care for these particular patients? Army Captain Nicole Brown, DPT: These are young service members that often want to return to a high level of function. Service members with limb loss may have goals of returning to combat or participating in strenuous activities such as marathons, rock climbing,

Meet the WRNMMC Contributors Dave Beachler, CP, is lead prosthetist, orthotics and prosthetics, department of rehabilitation, WRNMMC.

Army Captain Nicole Brown, DPT, is assistant chief, physical therapy service, department of rehabilitation, WRNMMC.

OCTOBER 2016 | O&P ALMANAC

Chris Dearth, PhD, is EACE facility research director, DoD/VA Extremity Trauma and Amputation Center of Excellence (EACE), department of rehabilitation, WRNMMC.

Brad Hendershot, PhD, is senior research biomedical engineer, DoD/VA EACE, department of rehabilitation, WRNMMC.

Barri Schnall, MPT, is physical therapist and clinical gait specialist, department of rehabilitation, WRNMMC.

Army Lt. Col. Jason Silvernail, DPT, DSc, is chief, physical therapy service, department of rehabilitation, WRNMMC.

PHOTOS: Walter Reed National Military Medical Center, Bethesda

Dave Beachler, CP: In general, both male and female service members are very active and often push the limits of prosthetic/ orthotic care to include endurance and high-impact activities such as running, snowboarding, and rock climbing. Allowing them to continue with their activities may take the most appropriate and best technology available in the industry. Because of the higher activity levels, it can be expected that their prosthetic or orthotic devices will need repair or updating on a more regular basis. Continued and timely access to care will be of the utmost importance for their overall success. Any delay in care may set them back. If there has been a delay in getting repairs or care, they often need to go through a retraining period to return them back to their previous activity level. This is when the team approach is very helpful in getting them back on track. I think that we need to remember that there will be setbacks from time to time, and we need to be prepared for that.

Army Lt. Col. Jason Silvernail, DPT, DSc: We recommend they take the approach we use here at WRNMMC—instead of moving a patient to their base functional level in terms of ADLs and work/job/school participation, ask yourself what is the maximum level of function you can help someone achieve? We often underappreciate how far our patients can go if they aren’t limited by our ideas about what clinical progress looks like. Engage them early on about what activities they like and will do in the long run—adapt the treatment and prescription to ﬁt their lifestyle as much as possible. Younger patients with limb loss have a full life ahead of them; that should include regular exercise and physical hobbies to maximize their quality of life. What adaptations can be made to allow that young man to keep hiking? To allow that young woman to keep lifting weights? Long-term care needs to provide function for current interests as well as support a healthy lifestyle in the long term.

Chris Dearth, PhD: Within the research and development section of the department of rehabilitation at WRNMMC, our research can be generally categorized into three main focus areas: advanced rehabilitation sciences; orthotics and prosthetics; and medical/surgical interventions. The first focus area aims to create and/or evaluate novel approaches to the rehabilitative care process, including more conventional physical therapy paradigms, but also novel technologies such as virtual and augmented reality. The Computer Assisted Rehabilitation ENvironment (CAREN) is one specific example currently being used to understand the interplay between cognitive and O&P Almanac: How can O&P professionals work collaboratively biomechanical processes among persons with lower-limb loss when with other medical professionals to ensure the best care for navigating an environment with varying levels of distractions and veterans over their entire lifespan? physical challenges (e.g., slopes and uneven terrain). The second focus area aims to create and/or evaluate novel Barri Schnall, MPT: From the moment a service member enters the prosthetic and orthotic technologies, such as intuitive control and military health system, his or her care is managed by a multidisciplinary team. It is important to carry this framework throughout the continuum of care. At WRNMMC, prosthetic and orthotic clinics enable multiple medical professionals to meet, evaluate, and treat a patient with extremity trauma in an efficient manner. The team consists of physiatrists, orthopedic surgeons, prosthetists, orthotists, physical and occupational therapists, case managers, nurses, and psychologists. Although many facilities do not have access to all providers under one roof, technology is available to enable telehealth applications to remotely access team members. Timely communication is achievable and essential to providing quality of care, thus achieving a high degree of patient satisfaction. weight lifting, or skiing. The service members’ goals need to be taken into account when selecting appropriate prostheses. Completing activities of daily living is often not enough to improve a service member’s quality of life. Rehab professionals need to treat these patients as tactical athletes. Active service members will test the limits of their prostheses. Be prepared to see these patients more often as they work toward their high-demand goals. These patients often need more frequent adjustments and socket updates, and may try multiple types of prosthetic devices to find the right combination to meet their aggressive rehab and life goals.

PHOTOS: Walter Reed National Military Medical Center, Bethesda

O&P Almanac: Can you share some details about the types of research programs currently in place to provide objective means and an evidence base from which to guide care?

O&P ALMANAC | OCTOBER 2016

evaluations of spine health and spine mechanics in service members with lower-extremity trauma (with and without low back pain) and an uninjured “control” group. “Evaluations of Knee Joint Health in Service Members With Unilateral Lower-Extremity Trauma,” which seeks to understand the onset and progression of osteoarthritis by investigating the relationships between intact limb knee joint loading during gait and image-based tibiofemoral cartilage properties in service members with lower-limb amputation. O&P Almanac: Is there any other information that you would like to share with O&P professionals?

OCTOBER 2016 | O&P ALMANAC

PHOTOS: Walter Reed National Military Medical Center, Bethesda

breathable prosthetic sockets. Projects in this area also seek to establish objective criteria for evaluating and prescribing orthotic and prosthetic devices; for example, evaluating the ability of prosthetic feet to accommodate weighted walking—an important aspect/component of dismounted military operations and other physically demanding occupations. Finally, and of particular importance and relevance to the long-term care of patients with extremity trauma, an overarching emphasis of the medical/surgical focus area is to further understand and ultimately eliminate the secondary health complications (e.g., back/knee pain or joint degeneration, cardiovascular disease) that these young individuals are at a pronounced and progressively increasing risk for developing. These efforts encompass activities that span the full spectrum of the research continuum—from basic science, to preclinical animal models, to human clinical trials— conducted by a multidisciplinary team of clinicians and researchers from disciplines such as physical therapy, physical medicine and rehabilitation, orthotics and prosthetics, biomedical engineering, and regenerative medicine and tissue engineering, among others. A few representative examples of ongoing studies within this particular focus area include the following: “Assessing Risk Factors for Cardiovascular Disease in Individuals With Traumatic Extremity Injuries,” which seeks to associate demographic/family history with a variety of measures for cardiovascular health in three cohorts (no injury, traumatic orthopedic injury with amputation, traumatic orthopedic without amputation) at baseline and longitudinal follow-up. “Evaluations of Spine Health in Service Members With LowerExtremity Trauma,” which seeks to investigate the relationship(s) between lower-extremity trauma and low back pain through

Brad Hendershot, PhD: Maintaining an active lifestyle is critically important for cardiovascular and physiological health, psychological well-being, and overall quality of life. Such guidance is just as important, if not more so, for the recent cohort of young military personnel with extremity trauma as they continue to live with these injuries for many decades to come. However, given the growing body of evidence relating movement abnormalities to altered musculoskeletal demands in this population, additional consideration for the quality of movement during recreational and daily activities is warranted to mitigate concomitant risk for the onset or recurrence of joint pain and degenerative changes. For the O&P community, speciﬁcally, substantial gaps in knowledge exist regarding how various prosthetic/orthotic technologies inﬂuence the risk for these secondary health concerns. Thus, we suggest clinical providers consider the long-term impact of traumatic injuries throughout the continuum of care, while researchers develop studies to generate objective data help guide clinicians during that process.

PHOTO:

(Continued from page 36) Bill Dunham, area clinic manager–Oklahoma for Hanger Clinic and a veteran himself, has a great familiarity with this patient population and their health-care needs. Dunham, a retired sergeant Bill Dunham of the Army’s 75th Ranger Regiment, was injured when he took part in the invasion of Panama have to be able to recognize that, and known as Operation Just Cause. After know what to do. You have to be willing several attempts to save his leg were to take breaks, or delay treatment, if unsuccessful, he became an aboveneeded,” says Clark. knee amputee nearly 27 years ago. “As You also should be aware that loud we all age, we begin to realize that our noises may bother this population, and ability to function is stymied by pain, the design of your facility may have flexibility, stamina, etc.,” says Dunham. an impact. “We just did a renovation “Because of this, veterans need to where we changed the seating so that reach out to medical professionals like none of the chairs back to walls, but physiatrists, prosthetists, or orthotists a veteran patient informed us that he to determine if a specific bracing and/ prefers seating against a wall,” says or prosthetic technology might be able Clark. “We rearranged” to accommoto enhance his or her life.” date the veteran’s preferences, he says. While many veterans are treated Dunham touts the importance of at VA clinics throughout the country, support groups for this population, some independent O&P facilities that and he backs that statement by being have contracts with the VA also care for a trained peer mentor through Hanger these patients. Hanger Clinic sees some Clinic’s AMPOWER peer support VA patients, particularly in rural areas, group. “I have been involved in the according to Carroll. “We, as indepencare of numerous veteran amputees over the past 10 years, primarily as a dent O&P facilities, when one of these peer/mentor through the AMPOWER patients comes in, we know that they’re program,” says Dunham. “This has in a good position with the VA,” he says. been an extremely rewarding opporWhen caring for veterans, “collaboration between the O&P professionals tunity as I did not have a support at VA hospitals and contracted O&P system when I went through my facilities is vital,” says Carroll. “We find amputation. Fortunately, veterans ourselves interacting with O&P staff, now have developed a strong network PTs, OTs, physiatrists—a team approach of peer mentors and extremely is critical for the success of the patient.” strong networks throughout the Carroll also stresses the importance primary military hospitals in D.C., San of accountability and documentation Antonio, and San Diego.” in working with the VA: “We need Educating veterans about activities to communicate, send emails docuthat promote an active lifestyle also is recommended, says Dunham. “There menting what is being done to evaluate are a number of different types of patients, and visit with VA officials.” activities available, including some that do not require prostheses,” he says. Sensitivity and Support “Sometimes taking a prosthesis off to While O&P practitioners should strive do activities—such as three-tracking to provide open lines of communication on the ski slopes, playing sit-volleyfor all patients, treating the military and veteran population may require extra ball, and sled hockey—can create huge sensitivity. Some of these patients have opportunities for these individuals. issues with post-traumatic stress disorI personally love having the option of skiing both with and without my der, which can linger for decades. “You

prosthesis; it just depends on how I feel that day and what kind of challenge I want to conquer.”

Inspiring Optimal Treatment

While providing appropriate technology in the devices veterans are able to select from is critical, it’s just as important to ensure a good overall patient-care experience, says Snell. “You have to have a heart to want to take care of this population,” he says. “They’ve done a lot for our country, and we owe them a superior level of service. What we lack in technology, we have to make up for in time and attention and caring.” “Veterans are a unique breed and are very resilient. They’re very appreciative of the care they receive. We need to ensure long and healthy lives for veterans,” says Clark. “Remember that how you make a prosthesis is not nearly as important as managing their care. We need to ensure a good quality of life” for veterans. “I see so many young veterans who have lived through some of the most horrific injuries, yet they constantly inspire others through their desire to thrive despite the challenges they face,” says Dunham. “It’s incredibly inspiring.” Christine Umbrell is a staff writer and editorial/production associate for O&P Almanac. Reach her at cumbrell@contentcommunicators.com. EDITOR'S NOTE: AOPA’s Veteran’s Affairs Committee maintains active communication with representatives at the VA and monitors and addresses any issue of national significance. For more information, contact Joe McTernan at jmcternan@aopanet.org. O&P ALMANAC | OCTOBER 2016

Former Sen. Bob Kerrey (D-Nebraska)

Two Keynotes, One Message:

PARTICIPATE!

SEN. BOB KERREY AND DAVID GERGEN URGE POLITICAL PARTICIPATION TO ENSURE A BRIGHTER FUTURE FOR O&P

ITH PATIENT CARE AND the advancement of the

O&P profession at a critical juncture during an important election year, the 2016 AOPA National Assembly planning committee sought out two well-respected political figures to share their views on the political landscape. Their keynote addresses to the more than 2,200 professionals in Boston in September offered insights on current events and optimism on the future of O&P.

Reaching Out to Legislators

Over the past year, former Sen. Bob Kerrey (D-Nebraska) has worked closely with AOPA and AOPA’s lobbying team to ensure a unified message for the profession. At the 2016 AOPA Policy Forum, he guided participants in authoring a one-page piece of legislation, the Prosthetic and Orthotic Care Modernization Act of 2016, which attendees presented at more than 350 appointments with Capitol Hill legislators and staff. As a result of the effort, similar provisions are now part of several bills pending in Congress. At the Assembly, the former governor told attendees not to be intimidated by the legislative process. “One of the misperceptions about laws and Congress is that you’ve got to be a lawyer to write a law, that you’ve got to be some kind of specialist in order to get that job done, and it simply 42

OCTOBER 2016 | O&P ALMANAC

is not true,” Kerrey explained. He further urged all O&P professionals to visit their senators and representatives and press them for a firm commitment on supporting the bill by getting it attached to a continuing resolution. “They’ll say, no, can’t be done; it’s got to go through the committee. It’s not true! It can be done, it has been done in the past, and it should be done in this particular case,” he said. “[Tell your representative or senator that] the bill will do a number of things: It will save money; it will reduce fraud and abuse; it will increase the middle class and the professionalization of the O&P community… and it will make it much easier for your patients to get the care that they need. “You can be forceful and respectful at the same time,” he continued. “There’s no reason to oppose this, no single reason to oppose this.”

Kerrey also fielded questions from the audience. One attendee asked for insights on CMS regarding the classification of O&P as durable medical equipment. “I talked to [CMS Acting Administrator Andy Slavitt] several times about it—that an orthotic and a prosthetic, that’s not DME, and it’s crucial that we get it moved away from just medical devices,” he responded. “I think Slavitt understands that, and I’m… guardedly optimistic that we’ll like the rule.”

David Gergen

Another attendee asked how the profession could be more proactive toward forcing a resolution to the proposed revisions to the Local Coverage Determination for LowerLimb Prosthetics. “I just don’t think there’s anything that you can substitute [for] just relentlessly going after this thing,” Kerrey said. “If you give 10 people off the street this piece of work, and they take 15 years to get it done, you would not give them a reward for that. They’re taking too long, and the whole process

of evaluating this thing is deeply flawed. So, I would not go in a gentle way to any member of Congress.”

Predicting the Vote

Later in the day, attendees talked politics at an executive level when David Gergen, co-director of the Center for Public Leadership at Harvard University and senior political analyst at CNN, shared his insights on the upcoming U.S. presidential election. Drawing on his 30-plus year career as a journalist and advisor to four U.S.

O&P ALMANAC | OCTOBER 2016

AOPA Announces Contest and Award Winners Lifetime Achievement Award

The Sam E. Hamontree, CP(E), Business Education Award

BEST

BUSINESS ABSTRACT

Molly McCoy, L/CPO, “Documentation Changes That Work! Proof That Better Documentation Leads to Overturn of Denials”

(Left) Tom Watson, CPO

presidents of both parties, he provided a historical look at the political landscape, and he offered his opinion on poll results in November. “We have seen the rise of two populist movements in this election campaign that have been totally disruptive, especially on the Republican side,” Gergen explained, noting that populism also has become critical in Western Europe, where 10 major countries have large populist movements that are now in governing roles. “But it’s a phenomenon we had not expected, came almost out of nowhere,” he said of the United States, citing stagnant economic growth for the past 20 years as a prime factor. “And what has also changed is the growth we do have, most of the new income that comes in goes upward and is not shared equally across classes. 44

OCTOBER 2016 | O&P ALMANAC

The people who’ve gotten hurt by this globalization and by technology, the people who have been increasingly left behind, are the blue collar, the working class of the country, that’s been so endangered and so hurt.” Gergen noted that O&P professionals may encounter patients who similarly feel abandoned when questions arise regarding whether they will receive the most appropriate prosthesis, or if they’ll be limited to one prosthesis per life. “You must run into this greatly; you must see a lot of these people,” said Gergen. “They’re, in many cases, your patients.” Enter Donald Trump, who has tapped into the working class frustration at feeling left behind, said

Gergen. And while he did not offer an assessment of the tactics of the Trump campaign, he did say: “I think you can be against Trump and be for trying to do something to hear the voices of these blue collar workers, to respect them, to [understand] the pressures they’re under, and [to] try to do something about it in our society.” Gergen also touched on the changing demographics in the United States and how they will determine our next president. Democrats are counting on an expanding voting base—namely minorities, young people, and women, he said. Meanwhile, the Republicans are “playing to the white base,” which is shrinking, he said.

Legislative Advocacy Award

Ralph Nobbe, CPO

Scott Schneider

James Young, Jr., CP, LP, FAAOP

Thranhardt Award

BEST

Kenton Kaufman, PhD, PE, “Functional Assessment and Satisfaction in K2 Transfemoral Amputees Receiving MPK Knees—Initial Findings”

Beatrice Janka, MPO, CPO, “The Effects of AFO Stiffness and Alignment on Lower Extremity Kinematics in Stroke and Multiple Sclerosis”

of SHOW

Edwin and Kathryn Arbogast Award

Tyler Klenow, “A Metric to Quantify the ‘Dead Spot’ Phenomenon in Prosthetic Gait: An Analysis of Sagittal Center of Pressure Progression and Its Velocity”

of SHOW

Otto and Lucille Becker Award

Morgan Oxenrider and Megan Kelly, “The Capacity Foot Orthoses To Modulate Plantar Foot Tissue Stiffness”

O&P ALMANAC | OCTOBER 2016

“When Bill Clinton ran for president, 88 percent of the voting population was white/Caucasian; we’re down to 68 percent. That makes a big, big difference, and if you’re going to win the presidency as a Republican, you not only need the white vote, you must make inroads into the

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African-American community and into the Hispanic community.” In the end, Gergen predicted a November win for former Secretary of State Hillary Clinton due to the popular vote, calling Trump’s path to victory “narrow.” In the past six elections, five have gone to Democrats

OCTOBER 2016 | O&P ALMANAC

and the popular vote. “There are 18 states, plus the District of Columbia, that have voted Democrat every single time, all six elections,” he said. “You need 270 electoral-college votes to win the election. That blue wall— those 18 states plus DC—gives you, as the Democratic candidate, 242. You get Florida? You’re in.” Assuming a Clinton victory, Gergen also pondered her ability to be effective and work across the aisle. “Nobody knows the answer to that question right now, because if the Republicans lose yet again, there’s going to be a fight over the soul of this party,” he said. Rep. Paul Ryan (R-Wisconsin) “is the natural bridge builder that she could work with in the Congress, but now Ryan’s got a mini-revolt coming from his far right, in his own caucus in the House.” What’s most probable, he said, is a year to a year and a half of governing, due to off-year elections in the Senate. However, he does predict a window of opportunity for Clinton to address the Affordable Care Act and getting costs under control. “Obamacare is not going to go away; you guys know that,” he said. “We’re not going to take health insurance away from people now. The question is, can you get off this unsustainable path?” In addition to sharing his personal anecdotes about the presidential candidates and other political figures, Gergen also took audience questions. Among them was advice for engaging the federal government and a new president. He suggested the O&P community align itself around the theory that Obamacare needs to be fixed. In exchange for that alliance, however, the profession needs the next president's “sympathy” on the issues that AOPA and the rest of the O&P community have been fighting for years. “I don’t know who’s going to run HHS if it’s Hillary. I doubt Sylvia Mathews Burwell will stay, but it should be somebody fresh to come in. I don’t know who’s going to run Medicare, Medicaid, but there are

Technical Fabrication Contest Winners

Articulating AFO Joint: Practitioners: • Rich Federman, CPO • Aaron Norell, BOCP, BOCO, CO Technicians: • Michael Brandon • Tim Cunningham Students: • Steve Daley • Todd Nakano

Winner Richard Federman, CPO, United Prosthetics Inc., presented by Brad Mattear, CPA, CFO

Aaron Norell, BOCP, BOCO, CO, IAM Orthotics & Prosthetics Inc.

Michael Brandon, SPS

Steven Daley, University of Hartford

going to be candidates out there, and I sure as heck would want to get to know some of the advisors who are going to be in place,” he urged. Storytelling and consistent communication with authorities are critical, according to Gergen. “So often in Washington, the problem is not people are malevolent; they just don’t get it.” Having a champion in Congress like Rep. Tammy Duckworth (D-Illinois), who fully understands

and appreciates the profession and its patients’ concerns, can be very powerful. “Look at how much influence [former Sen.] Pete Domenici (R-New Mexico) had over the years on mental health issues because his sister had mental health issues, and he made a big difference for legislation,” said Gergen. “Look at what [former Sen.] Ted Kennedy (D-Massachusetts) did; I mean, that’s a very special case, but individuals can be great

BK Socket and Foot: Practitioners: • Michael Stull, BOCP • Julianne Gupta, CPO Technicians: • Darrin Snowden, CPA, CTP • Michael Brandon Students: • Ashley Rinck • Allison Snooks

Allison Snooks, University of Hartford

champions of these causes. The American population is aging, and so your industry becomes even more important. I think you can amplify your voice. “So I wouldn’t count yourself out. [O&P] is not going to be the first item of business, but it’s going be a very, very important item of business within six months. And I would be working very aggressively to start building bridges now.” O&P ALMANAC | OCTOBER 2016

COMPLIANCE CORNER

By DEVON BERNARD

Dissecting the Standards Tips for complying with the 30 Supplier Standards

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ITH MEDICARE’S REVALIDATION CYCLE 2 in full swing, and with its continued use of the strengthened enrollment screening process— including site visits—for all Medicare, Medicaid, and Children’s Health Insurance Plan providers, the durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) Supplier Standards are taking on greater significance. Your compliance with the standards is even more important. This issue’s Compliance Corner examines the 30 DMEPOS Supplier Standards in detail, and offers tips for understanding each standard and an explanation of how to comply with each one.

STANDARD 48

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however, the standard does have some wiggle room. CMS and NSC have stated that contracting is considered acceptable for DMEPOS suppliers, unless they are in a state that specifically prohibits contracting. If you use contracted employees, be sure you can demonstrate that your state does not prohibit the use of contracted employees.

This standard deals with the responsibility of providing NSC with the most accurate and up-to-date information about your facility. At any time when completing your enrollment application forms, be sure to provide the most up-to-date

PHOTO: iStock.com/Sashkinw

This standard ensures that you are operating your business in accordance with all applicable federal regulatory, state regulatory, and state licensure requirements. Therefore, you must obtain all of the proper local and state licenses, and make sure you are licensed if you are in a state that requires licensure. If you are unsure what type of licensure your state requires, visit the website of the National Supplier Clearinghouse (NSC), the contractor in charge of enforcing the Supplier Standards, at www.palmettogba.com. The database offers information on the licenses you may require as well as the agency in charge of providing the licenses and contact information for each agency. You may want to visit the licensure database and double-check the information to ensure it is accurate. If the database incorrectly lists that you require a specific license, you will want to get the site updated before your site visit, or determine if something has changed and you now require a license. This standard was updated in 2010 to officially eliminate the use of contracted employees to provide licensed services;

STANDARD

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 49 to take the Compliance Corner quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.

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information. In addition, notify NSC of any changes in your business, such as a change in ownership, a new address, or dropping or adding a new product line, within 30 days.

STANDARD STANDARD

A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment and of the purchase option for capped rental equipment. This standard will typically not apply to an O&P supplier

because O&P items do not have a rental option. However, a site inspector may ask to see a form that you use to notify patients about the rental option. The NSC website has a notification form you may download and place in your operations manual to demonstrate that you have a form ready and available.

You must inform all of your Medicare patients about applicable warranties (state, manufacturer, company, etc.), and you must honor all applicable warranties, including free repair and replacement of any Medicarecovered items under warranty. Under this standard, you must be able to provide documentation that proves you provided warranty information to your patients; this can be accomplished with copies of letters, logs, or signed notices. The NSC has a notice template that you may use for your files if you don’t already have one.

STANDARD

Under this standard, you must be able to demonstrate that you have an adequate inventory on hand or the ability to obtain an adequate inventory to fill and complete orders, based on what you indicated you are providing to beneficiaries. This does not mean that you must have formal contracts with all of your vendors; a purchasing agreement or a credit letter is acceptable. However, the document should contain, at minimum, these specific terms: an established credit limit, credit terms, both companies identified in the terms, and the length of the contract or agreement. In addition, you may not contract with any entity that is currently excluded from the Medicare program. Doublecheck the Office of Inspector General (OIG) exclusion list at www.oig.hhs. gov/fraud/exclusions.asp to ensure any company you have a contract with is not excluded from Medicare or any other federally funded program—and continue to check the list on a routine basis to make sure that your contracted partners do not become excluded.

SS INE BUSO R D S REC

You must maintain and operate your business on an appropriate site, and the physical location of your business operations must have space for storing business records, unless you are a multisite business and you use a central record storage site.

STANDARD

This standard requires that an authorized individual must sign the enrollment application for billing privileges. Typically, this will be someone who has the legal authority to enroll a facility in Medicare—for example, a chief executive officer, chief financial officer, partner, chairman, or someone with a 5 percent or greater stake in the company.

“Business records” include proof of delivery forms, beneficiary communication records, and complaint forms. Follow these guidelines to make sure you are operating out of a valid facility on an appropriate site: The facility must be in a location that is accessible to the public and can easily be located and identified by patients as well as site inspectors. This means that it must have a valid U.S. Postal Service (USPS) address. Keep this in mind if you are located in a building or office complex utilizing suite numbers or some other designation; the suite must be a valid suite number recognized by USPS. In other words, you cannot have space in a building, then place a sticker on the door and call it “Suite A”—the USPS must recognize the suite number. The location must have a permanent, visible, in-plain-sight sign outside of the facility that identifies the business and posts the hours of operation. All interested parties should be able to find your facility and your hours of operation through the use of these permanent signs without any assistance from you or other parties. If your office is located within a building or complex, your signage may be placed at the main entrance of the complex or the lobby of the building, as long as it is visible. However, it is advisable to post your hours and information outside your door with a separate sign. In addition, your posted hours must reflect your true hours of operation, and they must match what is found on your most recent Medicare enrollment application. If you close for an hour during the day for lunch, your posted hours should reflect this closure. If your hours change, you should notify the NSC (see Standard 2). Your facility must be accessible and staffed during your posted hours of operation. This doesn’t mean that you must have an orthotist or prosthetist or any other clinical staff in the office during the hours you are open to the public, but there must be someone there. It is acceptable to have your facility hours “by appointment only,” as long as this information is posted and there is a way to set up an appointment, such as a contact number. O&P ALMANAC | OCTOBER 2016

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STANDARD

You must have a valid primary business telephone that is operating at the appropriate site, as defined by Standard 7. Cell phones, beepers, pagers, answering machines, and fax machines are not valid for a facility’s primary business phone. In addition, a phone number that exclusively forwards calls to cell phones, beepers, pagers, or another office is not considered a valid primary business number. In addition, a call answering service during posted hours is not considered appropriate. To be valid, the phone number should be listed under the name of the business in a local directory (phone book, Google, etc.).

STANDARD 50

OCTOBER 2016 | O&P ALMANAC

You are prohibited from calling beneficiaries to solicit new business, and you may only contact your patients if one of these three criteria have been met: 1. The beneficiary has given written permission to the supplier to make contact by telephone. 2. The phone call is related to a covered item that is to be delivered and you are contacting the patient to coordinate the delivery. 3. You have furnished at least one covered item to the beneficiary during the preceding 15 months. Remember this standard only restricts telephone contact as means of direct solicitation; it does not prohibit marketing via other methods. Advertising to the general public, by methods such as online, yellow pages, direct mail, and other electronic means of communication, is still permitted and not considered direct solicitation under this standard. In the past, OIG has taken an interest in this standard and released a special fraud alert regarding the prohibition of suppliers making unsolicited telephone contact with Medicare beneficiaries.

The alert focused on the practice of DMEPOS suppliers contacting beneficiaries solely based on an order provided by the referring physician and no written permission from the beneficiary, and the possibility that this practice may lead to unsolicited contacts. In the alert, it was clarified that suppliers may contact Medicare beneficiaries via telephone based on a physician's preliminary written or verbal order as long as the physician notifies those beneficiaries that a supplier will be contacting them to arrange the provision of their DMEPOS item or service. In other words, you cannot contact a new patient at the physician’s request, unless the physician has informed the patient that he or she has asked a supplier to contact the patient about providing the service. Remember that the beneficiary only needs to be made aware that someone will be contacting him or her regarding the item/service being ordered. This notification doesn’t need to be in writing; the patient does not need to sign anything; and the physician does not have to specifically name your facility. The beneficiary just needs to be notified that he or she may be contacted by a separate entity. If you receive a physician request to see a new patient, you may want to make sure that the physician has informed that patient that someone will be contacting him or her regarding follow-up care and the item or service being provided.

PHOTO: iStock.com/dcbog

Maintain up-to-date insurance records that show you have a liability insurance policy, in the amount of at least $300,000, that covers your place of business, including the employees and your patients. If you fabricate any items in-house, the insurance must include product liability

provisions. These insurance policies must be kept up to date; if they lapse for any reason, your Medicare billing privileges will be revoked and the revocation will be retroactive to the date the insurance coverage lapsed.

STANDARD

This standard gives permission to CMS, NSC, or any of their agents, such as Overland Solutions Inc. (OSI), to conduct site inspections to ensure your compliance with the Supplier Standards—and only the Supplier Standards. There is not much you need to do to be in compliance with this standard, except to allow CMS, NSC, or their agents to conduct a site inspection. How can you tell if NSC is there to do a site inspection, and how do you know the person conducting the inspection is an authorized agent of NSC? An authorized site inspector will always have a photo ID and a signed letter on CMS letterhead. If the individual doesn’t have the letter or the ID, or you have general reservations about the individual, you may contact NSC at 866/238-9652. The inspector may take pictures of your facility and may request to see patient charts, but he or she is not allowed to make copies of the charts or remove the charts from your facility.

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This standard does not apply to O&P facilities because O&P facilities do not rent items to Medicare beneficiaries.

STANDARD

STANDARD STANDARD

You must be willing and able to answer questions, or refer the patient to the proper entity, and respond to any and all complaints regarding the Medicare-covered items and services you provided. You also must document all complaints, including any actions taken to resolve the complaints. Consider creating a protocol that all employees follow when receiving and handling complaints. The protocol doesn’t need to be elaborate; it can be simple and straightforward as shown in the below sample text from the NSC website: “The patient has the right to freely voice grievances and recommend changes in care or services without fear of reprisal or unreasonable interruption of services. Service, equipment, and billing complaints will be communicated to management and upper management. These complaints will be documented in the Medicare Beneficiaries Complaint Log. All complaints will be handled in a professional manner. All logged complaints will be investigated, acted upon, and responded to in writing or by telephone by a manager within a reasonable amount of time after the receipt of the complaint. If there is no satisfactory resolution of the complaint, the next level of management will be notified progressively and up to the president or owner of the company.” In addition, if you receive complaints that may not be directly related to your services but may be more general in nature about Medicare or Medicare’s coverage policies, be sure you are able to point the patient in the right direction. Provide them with information regarding who they may talk to about their concerns, such as CMS, OIG,

or the durable medical equipment Medicare administrative contractors. Finally, to help you log, track, and document all of the pertinent information regarding complaints, see Standard 20.

You must accept returns from beneficiaries for items delivered that are deemed to be of substandard quality or unsuitable. This standard can become complicated because the definitions for “substandard” and “unsuitable” are a little vague, and the timeframe during which a patient may return an item for a refund is not set in stone. The standard defines “substandard” as anything that is “less than full quality for the particular item,” and “unsuitable” as anything that is “inappropriate for the beneficiary at the time it was fitted or sold.” This standard only refers to the act of accepting the returns of items, and it does not state that you must refund the patient, unless Medicare specifically requests, via an overpayment demand letter, that you refund the money. In the case that you must refund the money, you will want to be sure that you have documented or can otherwise show that you did not

STANDARD

This standard is easy to comply with because it requires you to do things that you normally do and are required to do if you are accredited. You must instruct beneficiaries on the proper use and care of items delivered to them, and you must obtain and keep on file a proper and valid proof of delivery, and documentation that the beneficiary received proper care instructions.

provide any substandard or unsuitable items, as this will help you in fighting the Medicare overpayment request. To demonstrate that you did not provide any substandard items, document that the items you provided were from a reputable supplier/manufacturer by showing your compliance with Standard 4—that the supplier/ manufacturer is not or has not been on the OIG exclusion list. If you fabricated the item in-house, you can explain that your fabrication methods follow industry standards and show that your raw materials are from reputable vendors. To document that you did not provide any unsuitable items, focus on two key areas. First, show that you delivered and provided exactly what was requested on the physician’s order, and that the item was appropriate for the patient. Second, document that the patient was satisfied and happy with the item at the time of delivery and fitting; and if there are any issues, document those issues and explain what you did to work with the patient and correct the issues. This documentation can ultimately demonstrate the patient’s acceptance of a suitable item and his or her happiness with the service/item provided. If the patient is returning an item stating that it is unsuitable or substandard and the item is under a warranty, explain to the patient that the item is under warranty and may be able to be replaced. This step will reinforce your compliance with Standard 6.

PHOTO: iStock.com/Steve Debenport

O&P ALMANAC | OCTOBER 2016

COMPLIANCE CORNER

OCTOBER 2016 | O&P ALMANAC

STANDARD

You may not convey, reassign, sell, rent, or allow another supplier to use your Medicare supplier number or billing privileges. Each supplier number must be attached to one physical location. In addition, each location needs its own Provider Transaction Access Number. The NSC has not interpreted any of the standards to come to this conclusion, but it is has officially stated that each location that is used to provide Medicare-covered items to beneficiaries must be enrolled separately. In essence, each location requires an individual supplier number. The only locations that do not require separate supplier numbers are locations that you use solely as warehouses or fabrication sites, places where you are not seeing patients, or places where you are delivering items.

You must have a written complaint resolution protocol in place to address beneficiary complaints that relate to the Supplier Standards. This is different and separate from the protocols created for Standard 13. The protocol does not need to be elaborate, and can be as simple and straightforward as the one you created for Standard 13. Remember that a log or record of these complaints and protocol must be kept at each physical location where you are providing a copy of the Supplier Standards or where you are treating patients.

In your complaint logs/ records for Standards 13 and 19, you must include the name, address, telephone number, and health insurance claim number of the beneficiary who lodged the complaint. You also should include a summary of the complaint and any actions taken to remedy it, even if no action was required. If you do not wish to create your own log, the NSC has a template you may use.

STANDARD

You must disclose information about any person, or entity, having ownership or financial or controlling interest in your facility—any person who has a 5 percent or greater stake in the company. This information should be disclosed in Section 8 and/or 9 of your Medicare enrollment application.

STANDARD

You must disclose and make the patient aware of the Supplier Standards for each and every Medicarecovered item and service you provide. There are three established methods to show compliance with this standard: • You may provide a copy of the standards to each patient and ask that he or she sign an acknowledgement of receipt; you should keep a copy of the acknowledgement in the patient’s record. This acknowledgement form/statement could be included with your proof of delivery forms, and the Supplier Standards could be printed on the back of the patient’s copy of the delivery slip, eliminating the number of pieces the paper the patient receives. • You don’t have to give the patient a copy of the standards if your acknowledgment statement includes directions on how the patient can locate and access the standards; in essence, you must make each patient aware of the standards. If you go this route, it is recommended that you use the following statement created by NSC: “The products and/or services provided to you by [supplier legal business name or DBA] are subject to the Supplier Standards contained in the federal regulations shown at 42 Code of Federal Regulations Section 424.57(c). These standards concern business professional and operational matters (e.g., honoring warranties and hours of operation). The full text of these standards can be obtained from the U.S. Government Printing Office website. Upon request, we will furnish you a written copy of the standards.” • It has been stated that simply posting a copy of the Supplier Standards in your office in plain sight for all patients to see would satisfy the requirements of Standard 16. However, the first two options provide you with a little bit more coverage in demonstrating compliance, and may prevent a patient or site inspector from saying, “I never saw the standards.”

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standards apply to your facility and how you can demonstrate compliance may be the difference between a successful site visit and an unsuccessful site visit.

A supplier must maintain ordering and referring documentation consistent with provisions found in 42 C.F.R. 424.516(f). You must retain your documentation for seven years, including the ordering/referring provider’s National Provider Identifier information.

This standard prohibits a supplier—a person or entity that has a Medicare approved supplier number—from sharing the same space with another supplier. In short, if two suppliers are billing for DMEPOS services/items, they cannot share space. Each supplier would have to have a separate approved location (Standard 7).

You may share space with a provider or supplier if that provider does not have a DMEPOS supplier number and is not providing or billing for DMEPOS items.

This standard requires offices to be open for a minimum of 30 hours per week. However, there is an exemption for O&P providers providing custom-fabricated prostheses and orthoses. To qualify for the exemption, you must have indicated on your enrollment application that you provide one or more of the following items/ services to Medicare beneficiaries: breast prostheses and/or accessories, cochlear implants, diabetic shoes/ inserts, eye prostheses, facial prostheses, limb prostheses, ocular prostheses, orthoses—custom fabricated, prosthetic cataract lenses, somatic prostheses, and/ or voice prosthetics. If you are providing any other items/services to Medicare beneficiaries, not including prefabricated orthoses, such as dynamic splinting or TENS units, then the exemption no longer applies and you are required to be open at least 30 hours a week.

STANDARD

STANDARD STANDARD STANDARD

Unless exempt, you must obtain a $50,000 surety bond for each of your enrolled facilities. To be exempt from obtaining the surety bond, you must meet the following criteria: The company must be solely owned and operated by O&P professionals (anyone listed as having any ownership stake in the company must be a certified orthotist and/or prosthetist); those O&P professionals must be the only ones seeing patients (if you employ other orthotists/ prosthetists and they are not part owners, then you would not be exempt); and you must be providing custom orthotic, prosthetic, and supply items. In addition,

This standard pertains only to oxygen and does not apply to O&P.

Knowing which

STANDARD

22-25

These standards relate to accreditation. There is currently an exemption for O&P providers from having to be accredited. However, this exemption only extends to orthotists and prosthetists. Pedorthists, orthopedic fitters, and mastectomy fitters working independently of an O&P company must be accredited. What’s more, this exemption only applies to items provided in the normal scope of the supplier’s specialty; any items provided outside of the supplier’s specialty will require accreditation. Thus, if you are providing any type of DME items (i.e., dynamic splinting, the WalkAide, the Bioness, canes, crutches, etc.), you would not be fully exempt, and would be required to be accredited for these items. In other words, you would not have to be accredited for the O&P items, but you would have to be accredited for the DME items. In such an instance, you should contact your accrediting body and determine how it handles partial accreditations.

if you are in a state that requires licensure, you must be licensed.

STANDARD

You must agree to furnish CMS any information required by the Medicare statute and implementing regulations. Complying with this standard would involve providing proof of delivery slips or detailed written orders when requested since these are required by Medicare statute for payment.

Knowing which standards apply to your facility and how you can demonstrate compliance may be the difference between a successful site visit and an unsuccessful site visit. Follow these tips to prevent a delay in receiving a Medicare supplier number or the revocation/suspension of a current Medicare supplier number. 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

Advanced Orthotic Designs

O&P in the Great White North Canadian facility specializes in orthoses for children and distributes pediatric footwear

REG BELBIN, CO(c), LAUNCHED Advanced

OCTOBER 2016 | O&P ALMANAC

Belbin became an AOPA member this fall, and enjoys collaborating with U.S.-based practitioners. “My experience in traveling to the States for meetings is that a lot of really good ideas germinate from my U.S. colleagues,” he says. “We have limited access in Canada to unique vendors and suppliers,” he adds. “If we want to grow and get more creative, we need to rub elbows with innovators and other people in the industry in the States.” Belbin recently attended the AOPA National Assembly in Boston to take part in business and scientific sessions—U.S. reimbursement and coding issues don’t apply in Canada—and looks forward to additional opportunities with AOPA. Looking ahead, Belbin plans to continue his facility’s growth, adding staff as needed. He continues to be interested in O&P innovation: “I’d like to create something unique for children with cerebral palsy,” he says. “We’ve got the skill set.” As Belbin looks to the future, he continues to enjoy his current patient base, and is especially pleased Trevor Da Silva, that patients CO(c), assembles and families an elbow orthosis. make return visits for their orthotic care. “Our patients have very busy lives, and ensuring continuity of care as they grow and develop is paramount in our practice,” he says. “Every time you can help someone out, you feel good at the end of the day. We know that people come to us looking for solutions, not more problems.” Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net.

1 year HISTORY: LP, CPO(SA) John Hattingh, CP, OWNER: Leesburg, Virginia LOCATION: FACILITY:

PHOTOS: Advanced Orthotic Designs

Orthotic Design (AOD) in 1997, after a 17-year career as director of applied technology and orthotic services at a large medical center in Ontario. “I did everything I could there, and I’d always wanted to go into private practice,” he says. He began as a solo practitioner; today he has six on staff, including certified orthotists Mark Faseruk Advanced Orthotic Designs staff and Trevor Da Silva; Kyla Copp, orthosis with neuromuscular an orthotic technician; and electrical stimulation. Kristin Byrne, who serves as AOD is the North American office administrator. The facility distributor of Piedro footwear, occupies a 2,900-square-foot designed in the Netherlands space in Mississauga, Ontario, FACILITY: for children with cerebral palsy. that comprises a waiting area, Advanced “The shoes are very well manfitting rooms, offices, and a large Orthotic Designs ufactured and open all the way fabrication workshop. AOD mandown to the toes to ensure ufactures the items it dispenses on LOCATION: there is no toe clawing, and a site, with the exception of shoes Mississauga, standard molded arch support and carbon fiber-based devices. Ontario comes with the shoe,” says As many as 70 percent of Belbin. “We’ve also just become AOD’s patients are children; OWNER: the second Canadian distribadults represent about 20 Greg Belbin, CO(c) utor for Keeping Pace pediatric percent of the facility’s case footwear, which can accomload, and sports orthoses HISTORY: modate braces and splints.” account for the remainder. In 19 years Belbin invented the SMART addition to on-site services, Walker™ orthosis, released AOD works with a number of in 1999, which is designed for pediatric treatment centers children with cerebral palsy. A in the area, as well as with customized brace fits around private physical therapists. the torso and lower limbs and The facility fits the full attaches to a wheeled frame, range of orthoses, including enabling the child to move with plagiocephaly helmets, upperhands-free support. Belbin plans and lower-extremity devices, to develop additional devices and therapeutic shoes and and is intrigued with integrating orthotic shoe inserts. “We are functional electrical stimulation the only company in Canada into ankle-foot orthoses. “I think authorized to fit the Gensingen Greg Belbin, there’s a role for that tech, but it’s brace for adolescent scoliosis,” CO(c), fits anklein its infancy in terms of battery says Belbin. AOD also offers foot orthoses. power and longevity,” he says. the Bioness L300, a foot-drop

By DEBORAH CONN

Who is an innovator? Who is held to the highest O&P standards? Who is committed to life-long learning? I AM. I am a big part of great possibilities.

1 year HISTORY: LP, CPO(SA) John Hattingh, CP, OWNER: Leesburg, Virginia LOCATION: FACILITY:

I AM ABC. Visit abcop.org today to find out what ABC can do for you. 703.836-7114

MEMBER SPOTLIGHT

Martin Bionics

By DEBORAH CONN

Orbital Inspiration Company focuses on improving socket interfaces

S A PRACTICING CLINICIAN,

OCTOBER 2016 | O&P ALMANAC

Jay Martin, CP

COMPANY: Martin Bionics LOCATION: Oklahoma City, Oklahoma OWNER: Jay Martin, CP HISTORY: 13 years

Socket-less Socket™

to create new ways of fitting prostheses. The result was the Socket-less Socket™, Martin’s alternative to the traditional static and rigid prosthetic sockets typical of most devices. Prosthetists can fit the Socketless Socket directly on the patient in real time, making adjustments in response to the patient’s direct feedback, and most fittings can be completed in a fraction of the time needed for conventional fitting methods. Once donned, the socket conforms around the residual limb and provides secure bony control. Some areas of the socket remain very compliant, such as the floating brim, which offers a greater degree of comfort. A lower trim line allows for the full range of hip motion. With the new device, “fitting a socket no longer requires the patient to return for several appointments,” says Martin. “The Socket-less Sockets are about 2 pounds lighter than conventional sockets, and patients can adjust them throughout the day, much like retying the laces of a running shoe to increase stability. The experience is like sitting in a soft hammock—not a hard chair.”

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

1 year HISTORY: LP, CPO(SA) John Hattingh, CP, OWNER: Leesburg, Virginia LOCATION: FACILITY:

PHOTO: Martin Bionics

Jay Martin, CP, felt that a lack of technological innovation was limiting his patients’ functional abilities. “We’ve come a long way in recent years, with much more sophisticated componentry, sensory feedback, and computercontrolled input,” he says. “But there is still a lot of room for innovation.” Martin founded Martin Bionics in 2003 to focus on advancing the state of prosthetic technology, working on autonomous control strategies, actuation designs, and socket interfaces. The company merged with Orthocare Innovations in 2007, but in 2009 Martin broke off to establish the next chapter of Martin Bionics, narrowing its focus to improving socket interfaces. In 2012, the National Aeronautics and Space Administration (NASA) invited Martin to transition his fabricbased socket technology into the space program to help mesh exoskeletal robotics and astronauts. NASA needed a more comfortable way of connecting the human into the exoskeleton. The success of that program led to invitations for Martin to play a lead role on two additional NASA exoskeleton programs, creating a man/machine interface that more comfortably and more securely spreads the forces about the body. “What we discovered and created on those programs resulted in a new understanding of how to connect man and machine with compliant fabricbased materials,” says Martin. His work with NASA led Martin to use those materials

Medicare recently gave its approval to the device, and as a result, Martin is seeing a substantial increase in sales. He plans to double his team within the next couple of months. Martin leads research and marketing activities for the company; other employees include engineers, clinical practitioners, and production staff. Most sales so far have been via word of mouth and the company’s website, as well as through trade publication advertising. Martin attended September’s AOPA National Assembly in Boston, where the company introduced new forms of suspension and new methods for managing tissue within the socket, as well as a new line of products to be available for the transtibial, transhumeral, and transradial fitting levels. “Our Socket-less Socket™ product line now benefits all levels of amputation,” says Martin. “The Socket-less Socket has been very well received by practitioners in the field. Thousands of amputees around the world are using our socket technologies,” says Martin. The company offers online training videos and face-to-face online training using video-chat programs as well as on-site visits by members of the clinical team. As for future plans, Martin’s goal is to change the status quo of how prostheses are fit on a global level. “We believe that our socket technology platform overcomes many of the issues that have challenged amputees for many years, and our latest in socket designs stand to radically impact how prostheses are fit in developing nations, making long-lasting comfortable sockets accessible to the 30 million amputees in developing nations who currently do not have access to prosthetics.”

AOPA NEWS

OCTOBER 12

NOVEMBER 9

Don’t Miss Out: Are You Billing for Everything You Can?

Knee Orthosis Policy: The ABCs of the Local Coverage Determination and Policy Article

Sign up for the November webinar, and make sure you are billing correctly. AOPA experts will discuss how to bill for the following: • Returned/refused items • Repairs and adjustments • Miscellaneous codes • Evaluations • Additional missed billing opportunities

Register for the October 12 Webinar Join AOPA experts for the October 12 webinar, and find out everything you need to know about the proposed Local Coverage Determination (LCD) and Policy Article for knee orthoses: • Examine which addition codes can be used with each base code. • Determine what documentation is needed for each type of knee orthosis. • Determine when you may use the KX modifier on a KO claim. • Review all other pertinent information found in the LCD 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 at bit.ly/ 2016webinars. Contact Ryan Gleeson at rgleeson@ AOPAnet.org or 571/431-0876 with questions. Register for the whole series and get three free webinars! The series costs $990 for members and $1,990 for nonmembers. All webinars that you missed will be sent as a recording. Register at bit.ly/2016billing.

OCTOBER 2016 | O&P ALMANAC

AOPA members pay $99 (nonmembers pay $199), and any number of employees may participate on a given line. Attendees earn 1.5 continuing education credits by returning the provided quiz within 30 days and scoring at least 80 percent. Register at bit.ly/ 2016webinars. Contact Ryan Gleeson at rgleeson@ AOPAnet.org or 571/431-0876 with questions. Register for the whole series and get three free webinars! The series costs $990 for members and $1,990 for nonmembers. All webinars that you missed will be sent as a recording. Register at bit.ly/2016billing.

AOPA NEWS

NOW AVAILABLE:

2016 Operating Performance Report AOPA Releases Results From Member Benchmarking Survey Copies of the 2016 Operating Performance Report are now available. The annual report provides a comprehensive financial profile of the O&P industry, including balance sheet, income statement, and payor information organized by total revenue size, community size, and profitability. This year’s data was submitted by more than 88 patient-care companies representing 1,164 full-time facilities and 71 part-time facilities. Copies of the 2016 Operating Performance Report are available electronically or print in AOPA’s bookstore: • 2016 Operating Performance Report (Electronic)— Member/Nonmember: $185/$325 • 2016 Operating Performance Report (Print)— Member/Nonmember: $285/$425.

Are you curious about how your O&P business is performing compared to others? Have you been asking questions like these: • How does our spending on materials, advertising, or other expenses compare with other companies similar to ours? • Is our gross margin better or worse than other facilities of the same size? • Are our employees generating enough sales?

EXTRAORDINARILY SIGNIFICANT FINDINGS: Medicare data proves the economic value of an O&P intervention.

O&P CARE is COST EFFECTIVE The Study that Started MobilitySaves.org

Reasons to visit MobilitySaves.org

Learn about the study proving orthotic and prosthetic care saves money

Find ads and videos on Medicare’ costcutting to share on your website or social media

A major study, commissioned by the Amputee Coalition with support from the American Orthotic & Prosthetic Association, shows that Medicare pays more over the long term in most cases when Medicare patients are not provided with replacement lower limbs. Mobility Saves Lives And Money!

See healthy lives affected by O&P care

Find resources to share with your patients

Learn how much Medicare has saved this year by providing O&P care

Visit MobilitySaves.org.

“Search Mobility Saves” on Facebook, Twitter, and LinkedIn

O&P ALMANAC | OCTOBER 2016

AOPA NEWS 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.

Advanced Biomechanics Inc. 215 N. Fireweed Street Soldotna, AK 99669 907/262-1515 Category: Patient-Care Facility Eric O’Guinn

Coachella Valley Orthotics and Prosthetics 75-150 Sheryl Avenue, Ste. A Palm Desert, CA 92211 760/345-4779 Category: Patient-Care Facility Camela Wilson

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.

Decker Integrated O&P 8931 W. 75th Street Overland Park, KS 66204 913/341-2661 Category: Patient-Care Facility Loren Decker, CP

Mobius Bionics LLC 470 Commercial Street Manchester, NH 03101 603/239-3834 Category: Supplier Level 1 Tom Doyon

Engineered Silicone Products LLC 75 Mill Street Newton , NJ 07860 973/300-5120 Category: Supplier Level 1 Michael Haberman

Seacoast Orthotics and Prosthetics LLC 155 Griffin Road, Unit 2 Portsmouth, NH 03801 603/294-0010 Category: Patient-Care Facility Chris Phillips, CPO

KMC Pedorthics 86-20 Jamaica Avenue Woodhaven, NY 11421 718/441-5621 Category: Patient-Care Facility Kim Castelli, CPed, CFo, CMO

Superior Prosthetics & Orthotics LLC 20075 Third Street Hancock, MI 49930 906/523-5896 Category: Patient-Care Facility Joan Laurn

MCOP Boston 500 Lincoln Street Allston, MA 02134 617/208-8468 Category: Patient-Care Facility Aﬃliate Medical Center Orthotics & Prosthetics LLC

The Source for Orthotic & Prosthetic Coding

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

Log on to LCodeSearch.com and start today. Need to renew your membership?

Contact Betty Leppin at 571/431-0876 or bleppin@AOPAnet.org. www.AOPAnet.org

OCTOBER 2016 | O&P ALMANAC

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

AOPA O&P PAC

O&P PAC Update

HE O&P PAC IS AOPA’s federally registered political action committee (PAC), AOPA’s lobbying branch, representing the O&P profession on Capitol Hill to ensure that your voice is heard during pertinent discussions and /or debates on legislation that may have an effect on the future of O&P. The O&P PAC is bipartisan and does not support one political party over the other, but instead the O&P PAC focuses on seeking out key legislators on key committees, who have demonstrated an interest and concern for the issues facing the O&P community. The O&P PAC then supports these legislators and their election efforts with a donation to their campaign funds and/or will help sponsor a fund raising event for these candidates. Since the O&P PAC is federally registered, it must comply with all of the rules and regulations of the Federal Election Committee (FEC). The FEC has very specific rules on who may contribute to a trade association’s political action committee. All O&P PAC contributions must be voluntary and come from eligible employees of AOPA member companies, including O&P practitioners, executive and administrative personnel, board of directors, stockholders, and their family members. All contributions from these eligible individuals must be made with personal funds. The O&P PAC may not accept contributions from corporate accounts. Also, monies collected by the O&P PAC cannot be used for government relations administrative functions, those things funded by Capitol Connection; they may only be used for direct or indirect support of federal candidates. To participate in and receive additional information about the O&P PAC, federal law mandates that eligible individuals must first sign an authorization form, which may be completed online: https://aopa.wufoo.com/forms/op-pac-authorization. PHOTO: iStock.com/sborisov

The O&P PAC would like to acknowledge and thank the following AOPA member for their recent contributions to the O&P PAC*: • Don DeBolt • Brad Ruhl • Scott Schneider

The O&P PAC recently made contributions to the following members of Congress: Sen. Charles Grassley (R-Iowa)

Rep. Tammy Duckworth (D-Illinois), currently running for U.S. Senate

Colleen Deacon (D-New York), currently running for New York’s 24th District seat

*Due to publishing deadlines this list was created on Aug. 19, 2016, and includes only donations received between June 30, 2016, and Aug. 19, 2016. Any donations made or received on or after Aug. 19, 2016, will be published in the next issue of the O&P Almanac. O&P ALMANAC | OCTOBER 2016

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.

ALPS EZ Flex The EZ Flex Liner allows users ease of knee flexion through an unlimited restriction of anterior stretch. The fabric has 80 percent less posterior vertical stretch, which reduces the bunching in the popliteal region. The EZ Flex is made with EasyGel that contains antioxidants that may help promote skin health, which also provides comfort and durability. For more information, contact ALPS at 800/574-5426 or visit www.easyliner.com. ALPS is located at 2895 42nd Avenue N., St. Petersburg, FL 33714.

PDAC Approved A5513 Diabetic Insoles Custom-milled, not molded, EVA and approved for Medicare billing by PDAC. Submit foam/crush boxes or Amfit digital orders for fabrication in three to five business days of receipt. Program pricing includes shipping to keep your costs low. Standard Bi-Lam and Tri-Lam plus toe fillers and Charcot foot styles. Do your office a favor and outsource your diabetic orthotic orders. Program services start with FootPrinter foam boxes where no equipment is placed at your office. For lower fabrication pricing and more control over the orthotic design, talk with us about FreeScan and lease purchase requirements. For complete details, please email sales@amfit.com or call toll-free 800/356-FOOT/3668, x266 or x264.

Amfit Contact LT 3D Digital Casting The Contact LT retains all the accuracy and automatic off-loading of the original Contact Pro Digitizer. Flash-Scan speed for casting and contour display in less than 10 seconds, thanks to eliminating the sensor lock. One button operates pins up, scan, and release, but sensor pressure is still adjustable to fit your preferred casting and treatment methodology. Offered in the FreeScan program, the Contact LT is a great addition to clinic offices and mobile service providers. As with all Amfit equipment, the LT is designed and built in the USA. For complete details on the Contact LT and FreeScan, email sales@amfit.com or call 800/356-FOOT/3668, x266 or x264, today. 62

OCTOBER 2016 | O&P ALMANAC

Peak Scoliosis Bracing System Winner of the 2015 Spine Technology Award, the Peak Scoliosis Bracing System is a revolutionary new bracing system from Aspen Medical Products. This innovative new concept in bracing is the only brace specifically designed for adults with scoliosis and has been shown to: • Significantly reduce pain • Increase mobility • Promote better posture • Improve the quality of life. Code L1005 approved. Visit www.aspenmp.com.

Sure Stance K3 Knee by DAW Industries HK-4PSC This ultralight, true variable cadence, multiaxis knee is the world’s first nonmicroprocessor, 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 not qualifying for a microprocessor knee. For more information, call DAW Industries Inc. at 800/2522828, email info@daw-usa.com, or visit www.daw-usa.com.

Cool Liner 2.0 Vertical Stretch Control (VSC) by DAW Industries Cool Liner 2.0 VSC DAW, the world’s leading manufacturer in prosthetic socket interface (DAW Sheath/ Sock), has improved upon our unbelievably advanced Cool Liner™ technology to create a thermoformable gel socket liner that provides a level of socket comfort beyond what is thought possible. You will never go back after using our new and improved Cool Liner with patented Vertical Stretch Control (VSC)—no other liner provides total elimination of Vertical Stretch with this level of comfort. For more information, call DAW Industries Inc. at 800/2522828, email info@daw-usa.com, or visit www.daw-usa.com.

MARKETPLACE Child Variable Cadence Multiaxis Knee Never heard of before: This ultralight miniaturized knee provides the ultimate in function and dependability for the active above-knee child amputee or smaller petite adults. Designed as a four-bar Pneumatic Polycentric, the kneeâ&#x20AC;&#x2122;s instantaneous center of rotation is projected proximally to the patient's residual limb. The specially engineered alloy construction accommodates the most active child amputee or lightweight adult with uncompromising strength and durability. For more information, contact DAW Industries Inc. at 800/252-2828, email info@daw-usa.com, or visit www.daw-usa.com.

LEAP Balance Brace Herscoâ&#x20AC;&#x2122;s Lower-Extremity Ankle Protection (LEAP) brace is designed to aid stability and proprioception for patients at risk for trips and falls. The LEAP is a short, semirigid ankle-foot orthosis that is functionally balanced to support the foot and ankle complex. It is fully lined with a lightweight and cushioning Velcloth interface, and is easily secured and removed with two Velcro straps and a padded tongue. For more information, call at 800/301-8275 or visit www.hersco.com.

Infinite TT The Infinite TT is a custommolded, modular, and adjustable socket system for transtibial amputees. The thermoplastic carbon-fiber frame, hinging posterior strut, and BOA closure system draw in the medial and lateral walls to improve biomechanical control. The advanced pressure distribution system incorporates height adjustment and air bladders, designed in response to activity demands, pressure areas, and shape change. The colorful range of soft shell covers allows patients to choose the right style for them. For more information, contact Press@LIMInnovations.com.

Infinite Socket TF The Infinite Socket TF is a custom-molded, modular, and adjustable socket system for transfemoral amputees. It encompasses a blend of advanced textiles and structural components, enabling transfemoral amputees to live beyond the limits of their prosthesis. Comprising of a modular carbon fiber, four-strut configuration, dynamic base-plate, and an adjustable brim designed to adapt and conform to limb fluctuation, the Infinite Socket TF is the first truly adjustable socket that both patients and clinicians can fine tune on the fly. For more information, contact Press@LIMInnovations.com.

Symphony Knee: Harmony Between Security and Fluidity The Symphony is a six-bar polycentric knee designed for patients who need both safety and dynamics. It orchestrates the phases of the gait cycle to offer a harmonious solution among security, comfort and fluidity. The p-MRS system mechanically detects the different gait phases and adapts stability accordingly. At heel strike, the system locks the knee geometrically and then cushions heel strike by a stance flexion dampening feature. The selective lock function enables the patient to lock the knee manually whenever security is needed. At the pre-swing phase, the Symphony unlocks for a smooth and effortless switch to swing phase. The powerful and compact-sized hydraulic cylinder ensures a natural gait. For more information, contact Nabtesco & Proteor in USA or by mail at Nabco Entrances Plant 2, S81 W18475 Gemini Drive, Muskego, WI 53150.

BUILD A

Better BUSINESS WITH AOPA

AOPA membership has its benefits. Visit www.AOPAnet.org/join today!

O&P ALMANAC | OCTOBER 2016

MARKETPLACE PROGLIDE 180—New Adjustable Cervical Collar from OPTEC USA The NEW PROGLIDE® 180 multi-post collar is the latest addition to OPTEC’s revolutionary PROGLIDE® cervical collars. The PROGLIDE® 180 comes in just one adjustable size, reducing inventory and saving you money. Both the anterior and posterior incorporate a height adjustment mechanism to provide a customized fit, resulting in greater motion control. Our new liner pads offer unparalleled support and comfort, especially to the mandibular and occipital pressure points. The PDAC Approved PROGLIDE® 180 is a complete solution for individuals with cervical injuries that require a collar for extended wear. For more information, visit www.optecusa.com.

Looking for a Cost-Effective and Easy Scanning and Prosthetic Ordering System? Now you can scan and order for under $400! Download our free iPad app to your iPad, and use a commercially available 3D sensor for a cost-effective scanning and ordering solution, saving you hours of labor and days of time compared to casting. The Össur Custom Solutions team can quickly design and fabricate your lower-limb socket, custom liner, or prosthetic solution, exactly how you want it, each and every time. And you won’t pay extra for smooth brim edges, alignment transfers, or even foam carvings. Learn more at ossur.com/c-sol.

C-Leg® 4 The C-Leg prosthetic knee can help your patients live more actively and independently, reclaiming the things that make life more fulfilling. Thanks to the speed at which stance phase resistance is adjusted, navigating crowds and walking on uneven terrain can be done more easily and confidently. Now weatherproof, the C-Leg 4 can stand up to a variety of conditions and daily activities. To learn more about the C-Leg 4 or to book a trial, talk to your local sales representative or go to professionals.ottobockus.com.

OPTEC USA’S Venum Hybrid— One Brace for All People Fabricated using the most advanced technology and materials, the New VENUM® HYBRID is the pinnacle of ONE-SIZE-FITS-ALL spinal systems. The VENUM® HYBRID accommodates patients of all different sizes and shapes with activity levels ranging from a young athlete recovering from a sports injury to a post-operative geriatric patient that requires immediate pain relief and comfortable support. The PDAC Approved VENUM® HYBRID features a streamlined design with either a single or double-pull cable pulley system and is designed to reduce inventory, thereby saving money, time and space. For more information, visit www.optecusa.com.

OCTOBER 2016 | O&P ALMANAC

SiOCX SiOCX sockets offer the best in comfort, function, and hygiene. Custom SiOCX sockets take advantage of HTV (high temperature vulcanization) silicone for the inner socket and carbon prepreg for the outer socket to offer incredible fitting solutions. The SiOCX family includes complete socket systems as well as stand-alone inner sockets. Although we have specialized solutions for transfemoral and transradial sockets, custom silicone devices can be made for almost all amputation levels. Extend your work bench and work with Ottobock, get a consultation today at professionals.ottobockus.com or talk to your sales representative.

MARKETPLACE precision. power. intelligent motion.

New Liner Option for WillowWood One System

Now available in four sizes! Call us today to learn more about our new i-limb™ quantum. For more information, contact Touch Bionics Inc. at (855)MY iLimb or visit www.touchbionics.com.

The WillowWood One® System provides transfemoral amputees comfortable, reliable, and secure suspension through the use of elevated vacuum or as a suction socket. The WillowWood One System equips transfemoral amputees with advanced socket technology that controls pistoning and allows for a broad range of motion while maintaining a secure socket fit. The System may now be used with the new Alpha Duo™ Liner! This liner provides the comfort of a gel liner with the durability of a silicone liner and retrofits with the fabricless Alpha SmartTemp® Liner. Certification required for system. For more information, contact WillowWood at 800/848-4930 or visit willowwoodone.com.

ADVERTISERS INDEX

Company

Page Phone

Website

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

703/886-7114

www.abcop.org

ALPS South LLC

800/574-5426

www.easyliner.com

Amfit

800/356-3668

www.amfit.com

Aspen Medical

800/295-2776

www.aspenmp.com

Baker College

810/766-4359

email: pedorthics-fl@baker.edu

Cailor Fleming Insurance

800/796-8495

www.cailorfleming.com

DAW

800/252-2828

www.daw-usa.com

Ferrier Coupler Inc.

810/688-4292

www.ferrier.coupler.com

Hanger Inc.

512/777-3800

www.EmpoweredCareers.com

Hersco

800/301-8275 www.hersco.com

LIM Innovations

844/888-8LIM

www.liminnovations.com www.nabtesco-proteor-usa.com

Nabtesco & Proteor in USA

855/517-4414

Össur

800/233-6263 www.ossur.com

Ottobock

800/328-4058

www.professionals.ottobockus.com

Texas Assistive Devices

800/532-6840

www.n-abler.com

Touch Bionics

855/694-5462

www.touchbionics.com

WillowWood

800/848-4930

www.willowwoodco.com O&P ALMANAC | OCTOBER 2016

AOPA NEWS

CAREERS

Opportunities for O&P Professionals Opportunities for O&P Professionals Job location key: Job location key:

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

Hire employees and promote services by placing your classified ad in theemployees O&P Almanac. When placing a blind ad, theyour advertiser may Hire and promote services by placing classified ad request thatAlmanac. responses be sent to anaad number, toadvertiser be assigned by in the O&P When placing blind ad, the may AOPA. to O&P box numbers are forwarded free of charge. requestResponses that responses be sent to an ad number, to be assigned by Include your company logobox withnumbers your listing of charge. AOPA. Responses to O&P are free forwarded free of charge. Advertisements and payments need to be received Include Deadline: your company logo with your listing free of charge. one month prior to publicationand datepayments in order to be printed in the Advertisements need to be received Deadline: magazine. posted and updated onlineinonthe the one monthAds priorcan to be publication date in orderany to time be printed O&P Job Board at jobs.AOPAnet.org. No orders or cancellations magazine. Ads can be posted and updated any time online on the are taken by phone. Submit ads by email to landerson@AOPAnet. O&P Job Board at jobs.AOPAnet.org. No orders or cancellations org fax to with VISA or MasterCard number, are or taken by 571/431-0899, phone. Submitalong ads by email to landerson@AOPAnet. cardholder and expiration Mail typed advertisements org or fax toname, 571/431-0899, along date. with VISA or MasterCard number, and checks name, in U.S.and currency (made outMail to AOPA) P.O. Box 34711, cardholder expiration date. typed to advertisements Alexandria, VAU.S. 22334-0711. edit Job and checks in currency Note: (madeAOPA out toreserves AOPA)the toright P.O. to Box 34711, listings for space and style considerations. Alexandria, VA 22334-0711. Note: AOPA reserves the right to edit Job listings for space and style considerations.

Mid-Atlantic

CPO/BOCPO

Elizabethtown, Kentucky At Center for Orthotic & Prosthetic Care (COPC), our staff of orthotic and prosthetic professionals is committed to our mission of providing the highest level of patient care possible. COPC is a private partnership that enjoys the privilege and challenge of serving in leading and renowned medical centers in Kentucky, Indiana, North Carolina, New York, and Pennsylvania. Due to the opening of the office manager position at our patient-care facility in Elizabethtown, Kentucky, we are seeking a CPO, or Kentucky-licensed BOCPO, with a minimum of five years of clinical experience. Candidates must possess excellent communication, organizational, and interpersonal skills, and the demonstrated ability to provide the highest quality patient care. This position offers a competitive salary, relocation assistance, and excellent benefits, including medical, dental, disability, 401K, certification, and licensure fees, and continuing education expenses. If you meet these requirements and have an interest, submit your resume, in confidence, to: Fax: 502/451-5354 Email copchr@centeropcare.com

O&P Almanac Careers Rates Color Ad Special 1/4 Page ad 1/2 Page ad

Member $482 $634

Nonmember $678 $830

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

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

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

Member Nonmember $85 $150

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

A large number of O&P Almanac readers view the digital issueâ&#x20AC;&#x201D; If youâ&#x20AC;&#x2122;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.

OCTOBER 2016 | O&P ALMANAC

Pacific CO/CP/CPO

Fresno/Sacramento, California, Medford, Oregon, and Richland, Washington Established in 1987, Pacific Medical Prosthetics and Orthotics has become a tenured company in the industry for patient-care products and services. With the heart of the company dedicated to helping and serving others, we are currently seeking four candidates as follows: A certified orthotist or a certified prosthetist/orthotist in Fresno and Sacramento, California; a certified prosthetist/ orthotist in Medford, Oregon; and a certified prosthetist or certified prosthetist/orthotist in Richland, Washington. We are looking for seasoned practitioners with experience in practice management, clinical expertise in outpatient and inpatient settings, organization and maintenance of an O&P facility, fabrication, fitting, and a willingness to work within a dynamic team. All positions as aforementioned are excellent opportunities for candidates that are self-driven/ motivated with an entrepreneurial spirit looking to produce results in an expanding market. Competitive salary, benefits and profit sharing offered based on experience. Interested candidates should email inquiries/resume to: Fax: 209/834-0690 Email: careers@pacmedical.com

CALENDAR

2016

orthotists, prosthetists, pedorthists, orthotic fitters, mastectomy 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.

October 12

Knee Orthosis Policy: The ABCs of the LCD and Policy Article. Register online at bit.ly/2016webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. Webinar Conference

December 3-4

ABC: Prosthetic Clinical Patient Management (CPM) Exam, Caruth Health Education Center. St. Petersburg College, FL. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.

November 7-12

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.

November 9

Donâ&#x20AC;&#x2122;t Miss Out: Are You Billing for Everything You Can? Register online at bit.ly/2016webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. Webinar Conference

November 14-15

AOPA Mastering Medicare: Essential Coding & Billing Techniques Seminar. The Tropicana, Las Vegas. Register online at bit.ly/2016billing. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. Seminar

December 1

ABC: Application Deadline for Certification Exams. Applications must be received by December 1 for individuals seeking to take the January ABC certification exams for

December 14

New Codes and What Lies Ahead for 2017. Register online at bit.ly/2016webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. Webinar Conference

2017 June 21-23

New York State Chapter of AAOP Educational Program. Albany Marriott Hotel, Albany, NY. Visit www.NYSAAOP.org or contact Joann Marx, CPO, FAAOP, at Marx4nysaaop@aol.com.

September 6-9

100th AOPA National Assembly and Second World Congress. Las Vegas. 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.

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

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Online Training 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.

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

CREDITS

Phone numbers, email addresses, and websites are counted as single words. Refer to www.AOPAnet.org for content deadlines. Send announcement and payment to: O&P Almanac, Calendar, P.O. Box 34711, Alexandria, VA 22334-0711, fax 571/431-0899, or email landerson@AOPAnet.org along with VISA or MasterCard number, the name on the card, and expiration date. Make checks payable in U.S. currency to AOPA. Note: AOPA reserves the right to edit calendar listings for space and style considerations.

Words/Rate 25 or less 26-50 51+

Member

Nonmember

$40

$50

$50 $60 $2.25/word $5.00/word

Color Ad Special 1/4 page Ad

$482

$678

1/2 page Ad

$634

$830

O&P ALMANAC | OCTOBER 2016

ASK AOPA CALENDAR

Open Enrollment Answers to your questions about participating and nonparticipating provider status

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

How do I change my participation status with Medicare?

Your participation status, or agreement with Medicare, is valid for one year and can only be changed during the open enrollment period. Any changes you make will not take effect until the start of the next calendar year. The Medicare open enrollment period is typically midNovember to the end of December. If you wish to change your status from a participating provider to a

nonparticipating provider, send a letter to the National Supplier Clearinghouse (NSC) during the open enrollment period. The letter should clearly state that you no longer wish to be a participating provider. The letter must be sent by December 31 and must be signed by a recognized, authorized official of your company. If you want to change your status from a nonparticipating provider to a participating provider, you must complete a Medicare participating provider agreement, CMS Form 460, during the open enrollment period and submit it to NSC by December 31. Can we have some of our locations/facilities be participating providers and some of our locations/facilities be nonparticipating providers?

The answer depends on how many tax identification (ID) numbers you have. The decision to be a participating provider or nonparticipating provider is tied to the tax ID of a company, and not to its locations or facilities. If you have multiple locations under one tax ID, you may not have some locations be participating and some locations be nonparticipating providers.

If I am a nonparticipating provider and I elect not to accept assignment on a claim, am I still obligated to meet all of Medicare’s billing requirements (medical necessity documentation, proof of delivery, etc.)?

Yes, you are still required to obtain all of the proper and necessary documentation. Your

OCTOBER 2016 | O&P ALMANAC

participation status only affects your ability to charge and collect your usual and customary charge and does not tie you to Medicare’s fee schedule amounts. If you are a participating provider, you are agreeing to accept Medicare’s payment as payment in full for all Medicare-covered items/services. If you are a nonparticipating provider, you may choose to not accept assignment, and you may charge and collect your full usual and customary charge from the patient. If I am a nonparticipating provider, may I still choose to accept assignment on claims and have Medicare send me its payment directly?

Yes, if you are a nonparticipating provider, you may choose to accept or not accept assignment on a claim-by-claim basis.

Correction: In the AOPA Answers department in the September issue of the O&P Almanac, L7510 was listed as “labor” and L7520 was listed as “parts.” The correct codes are L7510 for parts and L7520 for labor.

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