Reimbursement: The Future Is Now
By Paul T. Webber, CPO, FAAOP, ABDA, BOCPO The American population is growing older. The "baby
boomers" are getting to the age where they will increasingly rely
on the Medicare system to provide for their orthotic and prosthetic
needs.
 Due to medical and technological advances, people
who would not have been able to lead productive lives after an
injury, amputation, or survival of an illness now can. The loss of
a limb or the attack on the brain by a stroke now is not as much of
a limiting factor in living a productive life as it was in previous
generations.
The Medicare system will look to control these costs, which are
accelerating astronomically. The Centers for Medicare &
Medicaid Services (CMS) is looking closely at almost every product
or service in the O&P and DME field. O&P needs to distance
ourselves from the DME field; CMS sees the O&P field as
providers of products, not services.
Orthotists especially are going to be affected by this continued
association, since CMS sees items that can be fit and used by the
patient with little or no modification. These services are best
provided by certified orthotic fitters, not orthotists. The
orthotists' responsibility in the future will most likely be
determined by the need for custom-made devices.
Being able to document the need for custom-fabricating an
orthosis or a prosthetic socket or replacing prosthetic "hardware"
is going to be more vital than ever before.
Inappropriate L-Codes
The research in O&P has been directed primarily into
products that enhance the lives that they touch. These new products
take full advantage of the latest in materials science, but they
also carry a large price tag to the consumer. The fact that the
orthotics field finally has a stance control knee joint is a
tremendous breakthrough and has the possibility of enhancing many
lives. What was CMS's response? An improperly assigned L-Code that
severely limits the accessibility of this progressive technology to
patients who are covered under the CMS guidelines. Other
technological advances in the use of carbon fiber and acrylic
resins in orthotics are being down-coded to the point where they
cannot be provided at an appropriate rate.
The development of new items is also hindered by the time and
cost of obtaining an appropriate L-Code and a fair reimbursement
rate that covers materials cost and the necessary education,
research, and experience to provide these items.
Deep Discounting Drags Us Down
Insurance companies also are looking to decrease costs for
covered services. A discounted contract with a large O&P
provider makes sense to these entities; the value of services is
being lost. This situation is primarily the fault of the O&P
industry. The deep discounting that O&P providers are giving
HMOs is being noticed by CMS and other regulatory agencies. If the
industry can afford to greatly discount fees, then the mindset of
the regulatory agency is that the original fee must have quite a
bit of padding built into it. As the reimbursement rate is adjusted
to account for this, the ability to provide more than just a
product diminishes.
Research will go on wherever there is money to fund it.
Manufacturers are providing funds for education and research.
Manufacturers take on enormous risk and great costs, which are
built into the price of the item. If the investment in time,
materials, and money does not meet the projected return, then
research will dwindle.
Getting Fairer Reimbursement
Educating consumers, payers, and the public is critical. They
need to realize that O&P provides a vital service above and
beyond products--and that this service, along with the costs of
research and development of new and better devices, is built into
the costs to consumers and payers. We need to partner with other
organizations and allied health providers to educate patients and
payers. We need to separate ourselves from DME. And we need to stop
deep discounting. Paul T. Webber, CPO, FAAOP, ABDA, BOCPO, owns Chico Orthopedic Lab Inc., Chico, California. He serves as treasurer for the Board of Orthotist/Prosthetist Certification (BOC) and is a charter member of the American Academy of Orthotists & Prosthetists. 
Table Of Contents - October 2004
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