NAAOP O&P Capitol Hill Update for March 2022
The Centers for Medicare and Medicaid Services (CMS) recently issued two new regulations that impact patient access to orthotic and prosthetic (O&P) care, one on benefit category determinations (BCDs) and pricing decisions and one on prior authorization (PA). The first regulation improves the process for CMS to make BCDs and pricing decisions on new O&P technologies. The Health Care Common Procedure Coding System (HCPCS) Work Group at CMS will now make these determinations. The new process will be more transparent than under the current system, where decisions have been made in the halls of CMS with no public scrutiny. O&P innovators and manufacturers will now receive a preliminary determination on these important decisions, be granted a public hearing where supporting evidence can be presented, and questions will be able to be posed by the HCPCS Workgroup. It is not clear whether this system will produce better results, but it is certainly more publicly accountable.
In addition to an appropriate HCPCS code, an appropriate BCD or pricing decision on new technology is critical to ensuring that patients have access to O&P innovations. For instance, a new family of powered orthoses are entering the market. If CMS determines these orthoses are considered “durable medical equipment,” practitioners will have to demonstrate that they are medically necessary in the patient’s home—a DME requirement that does not apply to O&P—and could be paid on a rental basis rather than on a lump sum basis. This makes little sense for custom fabricated powered orthoses, but CMS’s decision on this issue is still pending.
On prior authorization, CMS also announced additional HCPCS codes that will be added to the list of items subject to PA. CMS implemented PA last year on a small number of advanced technology prosthetic components. Despite initial concerns, by all accounts, the program has been regarded by O&P practitioners as favorable, especially given the alternative of recoupments and long delays for ALJ hearings for denied claims. Now CMS is phasing-in application of PA to certain OTS orthoses, some of which are already subject to competitive bidding. These include two lumbar-sacral orthoses (L0648 and L0650) and three knee orthoses (L1832, L1833, and L1851). Some of these OTS orthoses are typically available and needed by patients at the point of a provider encounter and may not lend themselves to a delay in authorization under the PA program. More information is needed from CMS on this issue to ensure that this development does not compromise access to patient care.
Finally, NAAOP is proud to be working with our new President, Maggie Baumer, JD, who started her tenure on January 1st and would like to sincerely thank Glenn Crumpton, CPO, for his term as NAAOP President. NAAOP will host two Breece Fellows this summer, Nikki Grace-Strader and Lucas DeLuca, both of whom will be onsite in Washington, DC to absorb the intricacies of policy-making and O&P advocacy. NAAOP also plans to host a Virtual Congressional Fly-In this summer, where the Breece Fellows will play a key role in promoting the Medicare O&P Patient-Centered Care Act.
Thanks to all NAAOP members for their critical support in 2022