The Department of Health and Human Services Office of Inspector General released a report on October 10th, 2012 detailing the lack of CMS action on defining and limiting reimbursement for prosthetics and custom orthotics to “qualified” orthotic and prosthetic practioners as mandated by law (BIPA Sec. 427). The report states,
Section 427(a) of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) prohibits Medicare payments for prosthetics and custom fabricated orthotics unless the items are (1) furnished by a qualified practitioner and (2) fabricated by either a qualified practitioner or a qualified supplier. Section 427(b) of the BIPA required the Secretary to promulgate regulations to implement the requirements at section 427(a) of the BIPA.
The HHS OIG examined 1,135 Medicare-approved claims for prosthetics and custom fabricated orthotics in 2010 to determine whether the claimed items were furnished by qualified practitioners, were fabricated by either qualified practitioners or qualified suppliers, and met delivery documentation requirements. What they found was:
To date, CMS has not promulgated regulations related to BIPA payment requirements for practitioner and supplier qualifications for prosthetics and custom fabricated orthotics. CMS has used other legal authorities that limit who can be paid for prosthetics and custom-fabricated orthotics; notwithstanding, in 2010, Medicare allowed nearly 1,000 claims inappropriately. Despite the lack of regulations, most claims were allowed for prosthetics and custom-fabricated orthotics furnished and/or fabricated by practitioners and/or suppliers that were licensed, certified, or accredited.
CMS has made it a general practice in recent years to take the HHS OIG recommendations very seriously, so the O&P community could potentially see action on defining qualified practitioners in the next year, after having waited nearly 10 years since CMS has had original legislative authority to do so. Why is this important? Well, in the current regulatory environment many of the audits O&P professionals are receiving are due to a lack of medical documentation in physician notes, because the auditors are not allowed to include prosthetist notes in the file. Once CMS defines “qualified” practitioners and stops payments to “non qualified practitioners”, we as a profession will be one step closer to having the clinical nature of custom O&P defined as separate from the more general definition of a “supplier” of orthotics and prosthetics.
This is potentially a very positive step for the O&P profession. OPGA will continue to monitor CMS implementation of the OIG report, the full text of which can be found here.