Todays meeting with the Congressman (ALL Must Read)
M. Britt Spears CPO, FAAOP
Description
Collection
Title:
Todays meeting with the Congressman (ALL Must Read)
Creator:
M. Britt Spears CPO, FAAOP
Date:
4/29/2013
Text:
Hi List,
Well we had the meeting today with the US Congressman Stephen Fincher and his chief of Staff. Attending the meeting were representatives of 3 local O&P companies and a rep from Ossur. We discussed the dire audits and the effect on our industry. Below is a copy of what was given to the delegation plus the Duckworth letter (which he already knew about):
* Orthotics and Prosthetics (O&P for short) claims are based on delivered items such as eg, spinal braces or prosthetic limbs.
* O&P does not charge for follow-up care or office visits. We only charge for items delivered directly to patients. These items have a high out of pocket expense for the O&P companies.
* O&P providers are highly trained. The current educational requirements are a masters level program with specific courses very similar to Allied Health providers. 1 year classroom for each Orthotics and Prosthetics. 1 year residency for each of the programs courses O&P. That is currently for a recent graduate to become eligible to take the board exams- 10 years total education.
* Medicare has been for some time auditing medical providers including O&P claims.
* O&P is grouped under the broad umbrella of Durable Medical Equipment (DME).
* In 2002, Medicare created the qualified provider rule for who can deliver O&P items. This has never been enforced. In 2007, Tennessee Society of Orthotist and Prosthetist (TSOP) joined forces with the Tennessee Podiatrist Board of Licensure to enact state licensure for our O&P practitioners. This was to ensure the qualified provider rules were followed by the state.
RAC audits were the 1st to start with O&P. RAC auditors are private contractors. They work independently from Medicare. The range of audits changed dramatically. They started auditing the prescribing Physician’s records to make sure that they agreed with the items delivered. Whenever a Physician’s notes did not elaborate in enough detail, eg., patient is a community ambulatory, versus he is a community ambulator and has the desire to ambulate. The prior statement is not deemed sufficient for Medicare and therefore, Medicare will recoup their payment from the O&P provider. This places the O&P provider in a bad spot trying to police what the Physician has placed in their notes. If the patient dies within months of receiving the item, O&P providers risk refunding Medicare. RAC auditors are paid 10% of the recoupment up to $1000-whichever is least.
Pre-payment audits preformed by the MAC. We have to deliver the items then Medicare will review whether or not all of the criteria has been met before they will approve payments. Region B has had over 17% of small facilities close due to these audits. 75% of the facilities have had to cut staff. Prepayment audits delay payment to the O&P provider a minimum of 90 days. That’s 45 days for them to respond and 45 additional days for the documentation requested to arrive in their offices.
Claim denial findings:
* 4% are due to the Prosthetist lack of adequate documentation. This also says that 96% of the claims had the correct documentation provided by the Prosthetist.
* 32% of the denials are due to the Physician’s clinical records did not correlate with the Prosthetist records and did not justify the patient’s functional level
* OIG stated that 40.1% of custom orthosis claims were without proper documentation. These were submitted by O&P, Physicians, PT’s, OT’s and Orthopedic surgeons. Of that figure, 0.2% of the inadequate documentation was provided by O&P. That also means that 39.9% of the other submitters were without proper documentation.
This scheme is delaying services to patients. Because O&P is being targeted by CMS, we have to await Physicians notes and make sure they agree with our assessment. The average Physician has stated that they have no training in O&P and rely totally on O&P to determine what will provide the best outcome for the patient. It’s outrageous to expect O&P to police the Physicians.
If Medicare really wants to control fraud in the O&P industry (we account for at total of 0.6% of Medicare’s budget), they need to do 3 things.
1. Separate O&P from DME and allow ONLY O&P to bill Medicare for the “K codes”
* Enforce the qualified provider rule they themselves enacted in 2002. This alone would prevent fraud.
* Create a prior authorization system
I introduced him to my bilateral BKA patient who is a Veteran and retired US Marshall. The patient told his story about the value of have Prosthetics available and the constant need for adjustments. He explained about how his prosthesis are in a Prepayment review and exactly what he thought of that situation. That he wanted prosthesis instead of receiving a disability check. He wants to work.
The delegation was also told of how dire this is going to be on the under privileged. How they have to travel just to pay their light bill in person. How many have odd jobs just to get by.
The response from the Congressman was very eye opening. He stated that he has met with Physician groups, medical device manufacturers (Smith Nephew and Medtronic are in his district) and now O&P. He stated that the main problem is that nobody knows what is going to happen with the new ObamaCare. That these audits are across the board. That Washington has no money. There has not been a budget in over 3 years. This administration does not care. We are the low fruit on the tree and we will be consumed. He has never heard from AOPA’s lobbyist. That I was the 1st email he has received from O&P. That if we want to survive-contact your Congressperson and Senators. The squeaky wheel gets the oil. He does not hold out much hope for our situation. He also stated that after a certain age, prosthetic care will be denied. He said we will probably be absorbed into a government program-working for the government. He then apologized for having to be so honest.
Anyone want to buy an O&P business???
Call, email, sen letters tell your patients to do the same!!
Don't reply to me-take action and reply to ALL.
M. Britt Spears, CPO, FAAOP
The content of this communication is for exclusive use of the
addressee and may contain confidential, privileged and non-disclosable
information. If the recipient of this communication is not the
addressee, such recipient is strictly prohibited from printing,
photocopying, saving on any media, distributing or otherwise using the
information contained herein. If you received this communication in
error, please contact the sender by e-mail, fax or telephone and destroy this document.
Well we had the meeting today with the US Congressman Stephen Fincher and his chief of Staff. Attending the meeting were representatives of 3 local O&P companies and a rep from Ossur. We discussed the dire audits and the effect on our industry. Below is a copy of what was given to the delegation plus the Duckworth letter (which he already knew about):
* Orthotics and Prosthetics (O&P for short) claims are based on delivered items such as eg, spinal braces or prosthetic limbs.
* O&P does not charge for follow-up care or office visits. We only charge for items delivered directly to patients. These items have a high out of pocket expense for the O&P companies.
* O&P providers are highly trained. The current educational requirements are a masters level program with specific courses very similar to Allied Health providers. 1 year classroom for each Orthotics and Prosthetics. 1 year residency for each of the programs courses O&P. That is currently for a recent graduate to become eligible to take the board exams- 10 years total education.
* Medicare has been for some time auditing medical providers including O&P claims.
* O&P is grouped under the broad umbrella of Durable Medical Equipment (DME).
* In 2002, Medicare created the qualified provider rule for who can deliver O&P items. This has never been enforced. In 2007, Tennessee Society of Orthotist and Prosthetist (TSOP) joined forces with the Tennessee Podiatrist Board of Licensure to enact state licensure for our O&P practitioners. This was to ensure the qualified provider rules were followed by the state.
RAC audits were the 1st to start with O&P. RAC auditors are private contractors. They work independently from Medicare. The range of audits changed dramatically. They started auditing the prescribing Physician’s records to make sure that they agreed with the items delivered. Whenever a Physician’s notes did not elaborate in enough detail, eg., patient is a community ambulatory, versus he is a community ambulator and has the desire to ambulate. The prior statement is not deemed sufficient for Medicare and therefore, Medicare will recoup their payment from the O&P provider. This places the O&P provider in a bad spot trying to police what the Physician has placed in their notes. If the patient dies within months of receiving the item, O&P providers risk refunding Medicare. RAC auditors are paid 10% of the recoupment up to $1000-whichever is least.
Pre-payment audits preformed by the MAC. We have to deliver the items then Medicare will review whether or not all of the criteria has been met before they will approve payments. Region B has had over 17% of small facilities close due to these audits. 75% of the facilities have had to cut staff. Prepayment audits delay payment to the O&P provider a minimum of 90 days. That’s 45 days for them to respond and 45 additional days for the documentation requested to arrive in their offices.
Claim denial findings:
* 4% are due to the Prosthetist lack of adequate documentation. This also says that 96% of the claims had the correct documentation provided by the Prosthetist.
* 32% of the denials are due to the Physician’s clinical records did not correlate with the Prosthetist records and did not justify the patient’s functional level
* OIG stated that 40.1% of custom orthosis claims were without proper documentation. These were submitted by O&P, Physicians, PT’s, OT’s and Orthopedic surgeons. Of that figure, 0.2% of the inadequate documentation was provided by O&P. That also means that 39.9% of the other submitters were without proper documentation.
This scheme is delaying services to patients. Because O&P is being targeted by CMS, we have to await Physicians notes and make sure they agree with our assessment. The average Physician has stated that they have no training in O&P and rely totally on O&P to determine what will provide the best outcome for the patient. It’s outrageous to expect O&P to police the Physicians.
If Medicare really wants to control fraud in the O&P industry (we account for at total of 0.6% of Medicare’s budget), they need to do 3 things.
1. Separate O&P from DME and allow ONLY O&P to bill Medicare for the “K codes”
* Enforce the qualified provider rule they themselves enacted in 2002. This alone would prevent fraud.
* Create a prior authorization system
I introduced him to my bilateral BKA patient who is a Veteran and retired US Marshall. The patient told his story about the value of have Prosthetics available and the constant need for adjustments. He explained about how his prosthesis are in a Prepayment review and exactly what he thought of that situation. That he wanted prosthesis instead of receiving a disability check. He wants to work.
The delegation was also told of how dire this is going to be on the under privileged. How they have to travel just to pay their light bill in person. How many have odd jobs just to get by.
The response from the Congressman was very eye opening. He stated that he has met with Physician groups, medical device manufacturers (Smith Nephew and Medtronic are in his district) and now O&P. He stated that the main problem is that nobody knows what is going to happen with the new ObamaCare. That these audits are across the board. That Washington has no money. There has not been a budget in over 3 years. This administration does not care. We are the low fruit on the tree and we will be consumed. He has never heard from AOPA’s lobbyist. That I was the 1st email he has received from O&P. That if we want to survive-contact your Congressperson and Senators. The squeaky wheel gets the oil. He does not hold out much hope for our situation. He also stated that after a certain age, prosthetic care will be denied. He said we will probably be absorbed into a government program-working for the government. He then apologized for having to be so honest.
Anyone want to buy an O&P business???
Call, email, sen letters tell your patients to do the same!!
Don't reply to me-take action and reply to ALL.
M. Britt Spears, CPO, FAAOP
The content of this communication is for exclusive use of the
addressee and may contain confidential, privileged and non-disclosable
information. If the recipient of this communication is not the
addressee, such recipient is strictly prohibited from printing,
photocopying, saving on any media, distributing or otherwise using the
information contained herein. If you received this communication in
error, please contact the sender by e-mail, fax or telephone and destroy this document.
Citation
M. Britt Spears CPO, FAAOP, “Todays meeting with the Congressman (ALL Must Read),” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/235050.
