Report from the AOPA National Assembly - Part 1
Business Education Sessions
The quality and scope of the business education sessions at the national meeting of the American Orthotic & Prosthetic Association have been steadily increasing in recent years, and the 2006 Assembly reached a new pinnacle in this regard. Since most of the clinical sessions are reprised from the Academy meeting, I tried to attend as many business sessions as possible. As always, there were numerous concurrent business and clinical sessions, so it may well be that some of the best presentations are not being summarized in the Corner.
New Medicare Regulations
Joe McTernan kicked off this session with a thorough and well structured review of the impact of the 1993 Medicare Modernization Act and federal efforts to "streamline" the process. AOPA continues to do an outstanding job of staying on top of the ever-changing Medicare rules and - more importantly - interpreting the often arcane language in common sense terms that resonate with CPOs and clearly define our rights and responsibilities.
The DMERC system and its familiar A-B-C-D geographic regions are in the process of being replaced with a new structure that divides the responsibilities for reimbursement from adjudication. This complete restructuring of contractor duties is due in part to Congress's frustration with repeated embarrassing incidents where Medicare contractors paid millions of taxpayer dollars to criminal rings. The most recent debacle in Florida where Region C ignored State licensure laws paid millions for non-existent prostheses suggests that this change is well justified.
Under the new system, the Durable Medical Equipment Medicare Administrative Contractor [DME MAC] is solely responsible for processing and paying claims, including handling the first level of appeals. A new contractor called "MEDIS" will receive all electronic claims in the country, verify eligibility and determine the responsible jurisdiction, and forward the claim to the proper DME MAC. If this works as envisioned, it should make claims handling more consistent, particularly for "snow birds" and other beneficiaries who receive care outside their state of residence.
Unfortunately, CIGNA filed a protest immediately after the Center for Medicare and Medicaid Services [CMS] awarded the MEDIS contract and the court forced the contract be rebid. [CIGNA also protested the loss of the contract for what was formerly Region D but lost in court on this one although they prevailed and forced a rebid of the contract for former Region C.] As this article goes to press, the MEDIS contract has been officially awarded to CIGNA but the insurer who "lost" the contract is now appealing that decision.
It will be hard to evaluate the impact of these changes until Medicare has a stable "front end" in place although this sort of legal jockeying has certainly done nothing to make health care more affordable!
Once claims reach the correct DME MAC, their staff will take one of three actions:
- Reject "dirty" claims containing typographical errors or omissions
- Deny prescribed services it decides are not medically necessary or non-covered
- Process and pay whatever it considers "clean" claims
It is important to note that the new DME MACs will NOT be required to have a Medical Director on staff.
The make-up of the new A-B-C-D Jurisdictions is similar to the old DMERCs except that five states have been shuffled into new jurisdictions to match the new Part B Medicare MAC regions. Once the smoke clears, this too should make the system more consistent than before, although the states that have been moved may experience some "start-up" glitches.
Perhaps one of the most important changes is the creation of four new Program Safeguard Contractors [PSCs] who will focus on claims audits, fraud investigations, medical reviews, and development of medical policies. The PSCs are required to have a Medical Director on staff to supervise these functions. Clearly, Congress wants more physician oversight of the Medicare program and has opened the door to the creation of substantially more "administrative" hurdles to be overcome before beneficiary services will be reimbursed. The impact on access to P&O care remains to be seen.
One new wrinkle is that TriCenturian was the low bidder for the Jurisdictions A & B PSCs, so Dr. Hughes will now be the Medical Director for half the country. PSC-Trust Solutions won the bid in Jurisdiction C and so Dr. Oleck will be the Medical Director for that part of the country. PSC-IntegriGuard LLC won in Jurisdiction D and their MD, Dr. Pilley, has not previously been involved directly with the P&O community. It will be interesting to see the impact of having three physicians - including two with a good awareness of P&O issues - focus on medical policies and reviews.
The appeals process has been substantially revamped. Historically, Medicare has lost about 3 out of 4 appeals so the new system is intended to reduce this ratio. Whether this will be done by diminishing the number of faulty denials or by decreasing the odds of successful appeals remains to be determined. The new appeals process has five tiers:
- The first step in contesting a denial of prescribed care is to ask the DME MAC for a Redetermination [formerly called a Review]. This will be done by the non-physician staff of the insurance company who denied the claim in the first place.
- The second step is called Reconsideration and will be performed by a new Qualified Independent Contractor [QIC] whose Medical Director will handle all Reconsideration appeals for the entire country. Formerly termed "Fair Hearings", this change means that denials that have been upheld will then be reviewed by personnel who are NOT employees of the DME MAC who denied them, and supervision will be provided by a single physician which should result in more consistent decisions. The QIC Medical Director is Dr. Brennan, formerly of the Region C DMERC.
- If $110 remains in dispute, and Administrative Law Judge hearing [ALJ] is then permitted. Several smaller claims denied on the same basis can be combined to meet the $110 threshold. In one important change, the ALJs are no longer part of the Social Security system but are now directly supervised by Medicare.
- An unsuccessful ALJ ruling can be appealed within 60 days to a new entity called the Departmental Appeals Board [DAB].
- The last resort, only possible if at least $1090 remains in dispute, would be to file a civil action demanding a Federal Court Review. Since the beneficiary will be responsible for the cost of obtaining an attorney, many patients will not be able to access this theoretical appeal.
One of the most worrisome changes is that, under the new rules, additional information can NOT be submitted after the Reconsideration appeal. This means that the patient is now prohibited from offering further evidence in support of their appeal once it has been sent to the QIC. However, patients may be allowed to appear at ALJ hearings as an "observer" if a digital video of their function with and without the prescribed care has been submitted in the initial appeal.
It is therefore critical for anyone assisting a patient with appeals to formulate a complete and comprehensive initial argument with ALL useful documentation from the outset. If the QIC Reconsideration is unsuccessful, it is too late to add letters from the prescribing physician, independent physical therapist, or any other useful information to buttress the patient's arguments.
Kathy Dodson then highlighted the current state of the new Quality Standards from Medicare. These regulations are not yet finalized but, in general, seem to be a step forward from the prior policy of Medicare to pay anyone for P&O services who submitted a bill. In general, the new standards acknowledge the differences between O&P and DME. The original draft standards were more than 100 pages in length but, based on public comment, the current draft has been whittled down to 17 pages. Most of the unjustified requirements, such as evaluating the patient's home for adequate electrical service, have been deleted.
The standards are organized into three basic sections. The first is business services, including specific administration, financial management, human resources, customer service, performance management, product safety, and information management. For example, a compliance office must be designated; financial records must correlate with specific patients invoices, receipts, and deposits; personnel qualifications must be specified in terms of training, experience, and continuing education. In addition, professional staff must be licensed, certified, or registered and function with the scope of practice of the State; the referring must be notified within 5 calendar days if you cannot provide the prescribed care; copies of all complaints, investigations, and responses to patients must be kept on file.
The second section refers to general product-specific standards. This includes complete compliance with all Medicare regulations; documentation of patient education on use, cleaning, troubleshooting, maintenance and safety; follow-up consistent with the device and recommendations of the referring physician. All providers are legally required to comply with the full range of business and product-specific standards.
The standards conclude with a series of appendices that apply only to specific services and associated professionals. Appendix C applies only to "custom fabricated, custom fitted, custom made orthotics, prosthetic devices, somatic ocular and facial prosthetics and therapeutic shoes. Key requirements include training in a broad range of treatment options, access to equipment to handle fabrication and modifications, a diagnosis-specific exam, monitoring for complications, and appropriate follow-up care.
No date has currently been set for implementation of these standards. AOPA believes this is most likely to be phased in late in 2007, probably in those regions of the country that are subject to competitive bidding. Competitive bidding requirements will likely clarify many of the open issues.
Exhibition Hall
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Again this year, there was no real "buzz" about any one amazing technical advance that had never been seen before, although there was a lot of interest in the six patients at the OSSUR booth walking up and down slopes and stairs with their POWER KNEE and PROPRIO ankle-foot. However, there were a number of incremental advances in various areas of P&O care that were noteworthy.
Lower cost, lower resolution, limited-application digital input devices are appearing with increasing frequency. While some are little more than made-to-measurement Computer Aided Designs in digital trappings, these inputs do offer an avenue for the very small practice to begin to explore the use of non-contact input systems. One of the simplest was being shown by the French company, Orten, a newcomer to our market but a stalwart in Europe with a long history of producing the Lyon TLSO and related items. The Orten approach uses any contemporary high resolution digital still camera, combined with a calibrated "checkerboard", to capture sufficient digital silhouettes to permit creation of not only ready-to-fit body jackets and knee orthoses, but also transfemoral and transtibial test sockets, standing frames, seating systems, and even custom carved mattresses for patients with rigid deformities. For more information, visit the Orten web site.
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Townsend Design had a very intriguing hardware-based lower limb digitizer called the LaserCam at their booth. To create a custom knee orthosis, the patient rests his foot against a round, pizza-sized platform where it is stabilized by a hook and loop ankle strap. The practitioner then manually rotates a silver tube around the perimeter of the disk, where the integrated dual cameras and laser capture surface data measurements. This scanner can also be used to create custom AFOs, in which case the patient's foot rests on a clear plastic base so both plantar surface and shin data are gathered simultaneously. The entire digitizer fits into a small case for use at the hospital bedside or elsewhere in the community. More details can be viewed at www.medico-supplies.com, including a slick Flash animation demonstrating the versatility of this little unit.
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Campbell-Childs has a new concept in Dynamic Response feet they call the TRAKER, for Transverse Rotation All-carbon Keel. This prosthetic foot has a carbon fiber composite mid-foot keel plate that is perpendicular to the floor, while the distal keel is in the industry standard horizontal orientation. The biomechanical result of this geometric change is a foot with the expected dynamic response in the sagittal plane combined with a surprising amount of transverse rotation that occurs within the foot at a sub-talar level. This is the sort of clever insight that has always characterized Campbell-Childs offerings and it was nice to see that they haven't stopped innovating. They remain the only source for waterproof Syme feet and their standard waterproof foot is also available in a heavy duty configuration. Because they are now part of FORESEE, you can contact them for more information at www.4corthopedic.com.
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Scott Orthotic Labs, Inc. have developed a slick variation on the double action ankle joint they term Dyna-lock™ with a one-way locking mechanism that allows the patient to don their AFO with the foot in plantarflexion. Once the activator strap is fastened, the ankle joint then automatically locks in a pre-set amount of dorsiflexion, which can be altered as the patient's condition dictates. Because progressive dorsiflexion is permitted, this new component is well suited for patients with tight tendo-Achilles and may help reduce or prevent plantarflexion contractures in ambulatory applications. More information is available from www.scottorthoticlabs.com.
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One of the most clever new items I spotted was a line of lightweight sports shoes, for children an adults, that were hinged so the patient could slide the foot or brace into the shoe easily and then close the heel counter around the leg. These very cool and reasonably priced shoes are available from www.HatchbacksFootwear.com.
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Another "why didn't I think of that?" doodad was a very effective flexible plastic piece that patients can insert into their shoes while seated that eliminates the need for a shoe horn. Designed by Ian Engelman MS, CPO, the FootFunnel protects the heel counter and provides a slipper "guide" so the patient can slip the foot into their shoes. Once the shoe is donned, a simple tug on a long "shoelace" pops the FootFunnel out of the shoe. More details are available online at www.footfunnel.com or at www.insightful-products.com, where patients can order one for less than $12.
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