Blue Cross Blue Shield of Michigan recently announced their plan to reject DMEPOS claims submitted for orthotics and prosthetics if the submitting provider has not provided certifying documentation proving they are certified to provide orthotics and prosthetics. Providers will be required to bill with their appropriate provider ID #, connecting the complexity of the claim with the certification of the provider.
This language should sound familiar, because it is exactly what the orthotic and prosthetic profession has been banging on CMS’ door to implement on a federal level for nearly a decade. Way back in 2001, Congress passed the Benefits Improvement and Protection Act (BIPA), which included Section 427, requiring CMS to only reimburse licensed or otherwise qualified providers for custom orthotics and prosthetics. Unfortunately, CMS has chosen not to implement this important provision, leading to the reimbursement of thousands of providers that are not qualified to provide orthotic and prosthetic care.
The O&P profession over the past several years has worked with members of congress to create an additional piece of legislation, known as the Medicare O&P Improvement Act, to again instruct CMS to implement BIPA Section 427 and only reimburse those qualified to provide O&P. This bill would also provide a link between the qualification of the provider and the complexity of care/device that is being provided to the patient.
Slowly, too slowly, payers are beginning to pick up the pieces of BIPA Section 427 because it is smart policy that would actually prevent fraudulent payments from being paid out to providers in the first place — novel concept! With the current audit system, perhaps it would behoove CMS to implement policies to prevent fraudulent claims from being paid in the first place, rather than spending hundreds of millions of dollars trying to track those payments down after the fact and punishing honest providers in process!
Contact OPGA for more information, or view the release here