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OPGA Member Magazine

Attention to Process Details . . . page 4

2016 Audit Update . . . page 6

The Evolution of O&P . . . page 12

Be Prepared. . . page 2

SPRING 2016

NEWS from the President

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Having just returned from the AAOP conference in Orlando, I am struck by an intense sense of pride. Over and over, visitors to our OPGA booth came up to say, "Thank you. Thank you for helping us to be prepared to succeed in the business and professional environment we find ourselves in today." It is clear that OPGA's efforts to keep members informed about regulatory change and managing our patients with the most appropriate technology in a compliant manner has positioned independent companies to grow and succeed.

Here are some often repeated “thank yous” we heard last week:

• Thank you for helping in the battle to delay a flawed LCD.

• Thank you for helping us stay current with our CE requirements through in-person and online education.

• Thank you for aligning us with Wayne van Halem and his team to help improve our compliance and our businesses by improving our documentation skills.

• Thank you for standing up for the locally owned practices in all 50 states.

• Thank you for giving us quality purchasing options from manufacturers and a privately owned distributor.

• Thank you for providing comprehensive and affordable insurance via the leader in the

O&P market.

• Thank you for providing members clear and accurate referral source data to help us target growth opportunities.

The pendulum of power is swinging, and the playing field is leveling. Those who have transitioned by "being prepared" will reap the rewards you deserve.

OPGA and its membership will continue to do things the right way for the right reasons, always being willing to be measured by any and all stakeholders. So it is I who applaud you and sincerely thank you. Each of you plays a critical part in our profession’s success.

There is a new normal being raised for the patients we serve. A normal focused on their function, health and quality of life.

There is a new normal on the workplace battlefield as well. It seems the rules are the same for all providers, regardless of size or volume.

Serving you all,

Dennis Clark CPO

President, OPGA

Be Prepared

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Table of ContentsLetter from OPGA President Dennis Clark ................................................................................. 2

O&P1 ................................................................................................................................................. 2

Attention to Process Details Can Improve Your Practice's Efficiency

From PEL. ........................................................................................................................................... 4

PEL...................................................................................................................................................... 5

2016 Audit Update: What Can We Expect? .......................................................................... 6

By Wayne van Halem, The van Halem Group, LLC

The van Halem Group .................................................................................................................... 7

Össur® ............................................................................................................................................... 8

Premier Education Conference ..................................................................................................... 9

FLO-TECH® ....................................................................................................................................... 10

Targeted Referral Source Engagement Strategies for Independent O&P Providers ........ 12

By Ryan Ball, VGM Market Data

VGM Market Data. ........................................................................................................................ 13

The Evolution of Prosthetics and Orthotics: A 50-Year Perspective ....................................... 14

By John Tyo CP, BOCP, Director, Syracuse Prosthetic Center

Comfort Products, Inc. ................................................................................................................... 15

Breg® ................................................................................................................................................. 16

Langer Biomechanics ...................................................................................................................... 17

Brightree ........................................................................................................................................... 18

biodesigns, inc. ............................................................................................................................... 19

Border Patrol .................................................................................................................................. 20

Trulife ................................................................................................................................................ 21

VGM Insurance Services ................................................................................................................ 22

Knit-Rite®........................................................................................................................................... 23

Using Pneumatic Air Braces to Reverse Moderate to Severe Contractures ........................ 24

By John Kenney, BOCO, OCSI

OCSI .................................................................................................................................................. 25

OPGA Announces New Partnership with KT Health ................................................................. 26

KT Health .......................................................................................................................................... 27

Coyote Design ................................................................................................................................. 28

M-Brace™ ........................................................................................................................................ 29

Liberating Technologies, Inc. ........................................................................................................ 30

Drew Shoe ........................................................................................................................................ 31

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Wayne van Halem, The van Halem Group

2016 Audit Update:What Can We Expect?

It is an interesting time in the world of Medicare audits and contractors responsible for payment oversight. In 2015, we saw a decline in certain activity from the Recovery Audit Contractors (RACs), while seeing an increase in other activities from the Zone Program Integrity Contractors (ZPICs) and the Supplemental Medical Review Contractor (SMRC). The Affordable Care Act has expanded CMS’ authority to revoke the billing privileges of practitioners who show a pattern of improper billing. What does “improper billing” mean? When you look at the high error rates identified by this seemingly endless array of contractors who also have a lot of skin in the game, it is a scary thought to ponder. This article will summarize where we stand and provide some insight on what is to come.

RACs

Despite a hearing in 2013 and subsequent letter in 2014 regarding concern of the Recovery Audit Contractor program by the Senate Finance Committee, CMS seems to be pushing forward with an expansion of this program, albeit slowly. A significant reduction in activity occurred in 2015 mainly due to contracting issues and disputes, which still remain unresolved. In the most recent updates, CMS essentially confirmed that it was starting over with the contracting process. Essentially, CMS seemed able to successfully pursue extended contracts with each of the current RACs and, effective November 13, 2015, all RACs were able to continue audit activities through July 31, 2016. There have been a number of enhancements1 identified in the expanded program, but it looks like we’re back to square one.

While we don’t expect a significant increase in the RAC volume, one should certainly expect an uptick in comparison to 2015. The real volume increase can be expected when CMS finishes the contracting phase and makes a final award on the expanded program with enhancements. At that time, the RACs will be properly staffed and ready to go. It’s an opportunity for practitioners to avoid becoming complacent as the claims you are submitting now are the ones the RACs will go after later. So, ensuring that commitment to compliance with coverage policies and focusing on documentation is still key, despite the lull in activity. There is little doubt that RACs will once again focus on lower limb orthotics.

ZPICs/UPICs

While the RACs have been laying low, the ZPICs have done quite the opposite. These contractors, responsible for identifying and preventing fraud, waste and abuse, have been increasingly active again. We’ve seen an increase in the number of large, extrapolated overpayments and other aggressive actions, including payment suspensions, against providers and suppliers. In some instances, these actions are taken against entities for issues that, in the past, we would have experienced a very different outcome. The volume and intensity of these audits increasing is also, coincidentally, timed with another reform in the contracting of program integrity workload. In June 2015, CMS released a pre-solicitation notice to interested parties that they would be releasing a Request for Proposal (RFP) for Unified Program Integrity Contractors (UPICs). The notice indicated, “…the UPIC will combine and integrate existing CMS program integrity functions carried out by multiple contractors and contracts into a single contractor to improve its capacity to swiftly anticipate and adapt to the ever-changing and dynamic nature of those involved in health care fraud, waste and abuse across the Medicare and Medicaid program integrity continuum.”

What does this mean to you as a practitioner? From a ZPIC perspective, it means the work currently being performed under their current contracts will be transitioned to another contract. It means the possibility exists that the lucrative government contract they have may no longer be theirs. It means a loss of revenue and employees for these stakeholders. As a result, we see these existing contractors turn up the heat. The more overpayments they can identify, the better the cost savings to the program they can tout to CMS in their bid for a UPIC contract. Why identify an actual overpayment when you can extrapolate those results and identify a much larger overpayment? Essentially, these contractors are trying to show CMS a return on its significant investment. That means a lot of claim denials and overpayments.

In addition, we see other actions for which the ZPICs are responsible for, such as payment suspensions, being considered and implemented for issues that previously may not have warranted them. A pattern of minor or technical billing errors can result in a provider or supplier being put on prepayment review, facing a large extrapolated overpayment or having payments suspended. In recent correspondence to providers, the ZPICs are using language citing their authority2 to revoke

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billing privileges when “CMS determines that the provider or supplier has a pattern or practice of submitting claims that fail to meet Medicare requirements.”

The amount of money at stake in these contracts is hundreds of millions of dollars. When the ZPIC contracts were awarded during the initial rounds, the collective contract awards amounted to well over half a billion dollars. Consider the amount a company could be awarded when these contracts are consolidated even further. In their line of business, it is an opportunity, but that opportunity could wreak havoc on a practitioner who finds itself dealing with a ZPIC in this environment. The OIG has often criticized CMS for a lack of oversight over its contractors, including the ZPIC3, and that becomes an even bigger hurdle for providers and suppliers to overcome when there is an incentive for the auditor.

As of today, the RFP responses for an umbrella UPIC contract have been sent, and contractors are eagerly awaiting a response from CMS. Once umbrella contracts are awarded, the competition will heat up for specific UPIC contracts identified.

Supplemental Medical Review Contractor (SMRC)

The SMRC is exactly how it sounds. Another government contract awarded to a company, in this case Strategic Health Solutions, to supplement the work already being performed by current contractors. Regular medical review functions are the responsibility of the administrative contractors and fall under the scope of work. Strategic Health Solutions will supplement that work by performing national reviews as directed by CMS. While the goal of the program is to reduce the improper payment rates and increase efficiencies in the medical review program, it equates to more audits and more overpayments for providers and suppliers. The SMRC has a long list of completed projects across the continuum of health care services4, and current projects include electro-diagnostic testing, inpatient psychiatric facility services, radiology, radiation therapy, bariatric surgery, blepharoplasty services and various types of durable medical equipment. There is nothing yet confirmed or announced by the SMRC related to O&P, but it is not outside the realm of possibility.

2016 OIG Work Plan

Lastly, in regards to the OIG Work Plan for 2016, we are pleased to announce that lower limb prosthetics have been removed as an issue after two years of being included in the plan; however, orthotic braces have been added to the list.

The OIG is going to review provider compliance with payment requirements to determine whether providers’ claims were medically necessary. The OIG indicates that its prior work indicated that some providers were billing for services that were medically unnecessary (e.g., beneficiaries receiving

multiple braces and referring physicians not seeing the beneficiaries). We think for most of the membership reading this article, this should have minimal impact. We believe the focus of these reviews will be the huge increase in mail-order orthotic suppliers throughout the country.

When CMS implemented competitive bidding on a national basis for mail order diabetic suppliers, many companies were forced out of the diabetic supply business and looked for something else to provide that was not subject to competitive bidding. It seems that back, knee, ankle, shoulder and wrist braces were the go-to products. CMS has seen an increase in volume. Essentially, anyone with an arthritis diagnosis seemingly was getting a brace. Lead-generation companies popped up nationally, providing hundreds of leads per month to these providers. The marketing is direct-to-the-beneficiary via late night commercials and Internet ads. As a result, the beneficiaries often have not seen their physician for an evaluation, and most do not qualify for the braces they are receiving.

For the legitimate practitioner, just understand the documentation requirements. Many of these types of orthotics have KX modifier requirements that state you have documentation in your files prior to billing that supports that the patient meets the criteria outlined in the coverage policy. If you follow that guide, you may get caught up in the review process, but they shouldn’t scare you. In fact, it may very well be a welcome sight as they crack down on companies that give legitimate orthotic practitioners a bad name.

1 https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-

Programs/Recovery-Audit-Program/Downloads/Recovery-Audit-Program-Enhancements11-6-15-Update-.pdf

2 42 CFR 424.535(a)(8)(ii)

3 http://oig.hhs.gov/oei/reports/oei-03-09-00520.pdf

4 http://strategichs.com/smrc/medical-review-results/

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Have you ever wondered how your competitors stay in business? If you are working with the key referral sources in town, who do they work with? In today’s world of providing custom orthotics and prosthetics – with audits, endless documentation requirements and declining reimbursement – independent O&P providers must leverage business from more physicians if you are to remain relevant and thrive in difficult times. Imagine if you could, at the click of a button, identify a list of the top referring physicians in your market?

To answer that question, we first needed to identify where referrals for orthotics and prosthetics originate. Over the past year, OPGA has conducted outreach to multiple members seeking input on what type of physician specialties typically make up their largest number of referral sources. The consensus was that orthopedic and vascular surgeons (the largest group), podiatrists, family practice, physical medicine and rehabilitation and geriatric physicians make up the vast majority of referral sources, but the frequency fluctuates depending on the individual market.

After determining the specialties of the most likely physicians that provide care to a patient in need of orthotic and prosthetic intervention, we then conducted an analysis of which procedures and diagnoses are most utilized by these types of physicians. The goal was to identify physicians treating patients from pre-surgery through amputation and post-amputation follow-up care. Obviously the list begins with above- and below-knee amputations, revisions, upper extremity amputations, hip and ankle disarticulation, post-amputation status codes, infections of the stump, diabetes and gangrene, to name a few.

With clinical research of target physician practices treating patients in need of O&P complete, we began to identify and rank key physicians based on the volume of procedures or diagnoses attributable to their National Provider Identifier (NPI) number. In addition to this inpatient and outpatient targeting data, we can now focus on claims being submitted by O&P providers to determine the breadth of local competition and their relationships with key local physicians referring for O&P. Referral source claims data is available for virtually any HCPCS or L-code. Orthotic knee bracing, spinal bracing and lower limb prosthetics are some of the more popular categories for O&P providers to target.

The diagnostic and claims data utilized throughout this research came from an exciting new program called VGM Market Data.

VGM Market Data is a physician-level DMEPOS claims data program offered exclusively to OPGA/Point members for orthotics and prosthetics. It offers access to the largest and most comprehensive medical claims database in the United States to target key procedures, claims, products and referral sources.

By now I’m sure many readers are thinking, “If I had access to accurate targeting data, what would I do with it?” Many independent O&P practices do not employ “sales” or “marketing” people. In fact, many of the practitioners we spoke with are often forced to reduce time seeing patients to make a trip to physician offices, or they simply do not do traditional sales and marketing. Accurate and volumized targeting data allows an independent practitioner to see more patients and touch more referral sources by focusing on just the select few physicians that you know have additional volume or value for your practice.

Identifying the “big fish” and prioritizing resources to create a targeted plan of engagement is just one piece of a marketing plan. After identifying the top referral sources in your market, you also need to segment them into manageable contact groups based on their potential value to your practice. One common strategy includes segmenting your target physicians into three basic groups, each with its own value and marketing contact plan.

For instance, say you identify 10 physicians that are the primary drivers of custom prosthetic referrals in your market. These are your “Rank 1s;” they get the red carpet treatment, an in-service at their office on key facets of prosthetics and monthly “touches” in the form of visits, phone calls to discuss recent patient success and direct mail pieces increasing brand awareness by providing success stories on your comprehensive prosthetic care management solutions. Obviously it is not practical for an independent practitioner to provide physician in-services for every potential referral source, so what happens to the next tier of referral sources? They get their own contact plan, but it does not include individual in-services; perhaps they receive a visit, phone call about a specific patient and branded direct mail. The key point here is that more time and resources need to be spent wooing the high-value referral sources for your practice. Having the ability to prioritize based on volume is a game changer for independent practices looking to grow their business and brand. Additional segmenting options present themselves after the initial outreach plan and after reviewing results within each grouping.

Targeted Referral Source Engagement Strategies for Independent O&P Providers

By Ryan Ball, Director, VGM Market Data

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By Ryan Ball, Director, VGM Market Data

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The effects of exponentially accelerating changes in the prosthetic and orthotic profession are not going to slow down!

The late 19th century saw the beginnings of major changes in medicine worldwide but particularly in the United States. Between about 1840 and 1900, medicine went from being a medieval art (think barber poles and bloodletting) to incorporating many elements of modern science. Advances in chemistry and biology had major impacts on medicine. As medical practitioners began to understand that the body was comprised of basic chemicals and not mysterious “humors,” effective treatments for diseases and injuries were developing. Purgings and bloodletting went out of vogue.

As medicine became more scientific, it became clear that doctors needed both training and licensing. In 1847, Dr. Nathan Davis founded the American Medical Association (AMA) to help establish professional standards for doctors and set minimal educational requirements. Medical schools were developed across the country. Educational requirements were gradually expanded from a few months without any college background to a number of years with a college degree a prerequisite and eventually a residency and established boards.

My first job in prosthetics was sweeping wood chips for 10 cents an hour. I was fascinated watching my father, a veteran and amputee, turn hunks of wood and steel into moderately realistic facsimiles of human limbs that returned some measure of “normalcy” to an amputee’s life. Everything – sockets, knees, feet and suspension systems – was fabricated in his “shop.”

Doctors today no longer routinely bleed people (the nine pints of blood in 24 hours the doctors drained from George Washington for his throat infection probably didn’t greatly increase his chances of survival), and prosthetists today don’t routinely try to stuff a patient’s residuum into a hollowed out block of wood. Both professions have evolved, and the educational requirements and oversights of ethical practice have evolved with them. Neither profession initially mandated malpractice insurance to ply their trade. Today both do.

I now have in my pratice a son and son-in-law with degrees in molecular biology and business, respectively. I joined an industry. They joined a profession. I attended short-term courses at Northwestern University. They attended differing undergraduate schools, Feinberg Medical School at Northwestern University,

completed residencies and then passed stringent boards to affirm their right to practice and prove they had earned the right to procure the necessary malpractice insurance coverage required to practice.

There has been a steady progression in the educational needs and practitioner capabilities in treating prosthetic patients. There has been a steady separation of skills and educational requirements of the prosthetic practitioner who requires training and malpractice insurance to treat a patient and manufacturers who are developing increasingly sophisticated prosthetic componentry and interface systems. To be sure, there are significant overlaps in the prosthetic profession and the prosthetic industry, but they are separate entities with separate educational needs, and as the separation grows, the need for separate representational bodies will also continue to grow.

Both the profession and the industry require governance and oversight, but a proper understanding of the roles of each must precede the governance and oversight of each.

That the evolution of the prosthetic profession requires changes to bring the profession into uniformity with contiguous LCMP (licensed certified medical professional) groups is indisputable. That to properly accomplish this will necessitate the cooperative input of the prosthetic profession, the prosthetic industry, the prosthetic educational institutions, the government, amputee advocacy groups and multiple medical groups with an interest in an amputee’s successful long-term physical and mental outcome to their loss and challenges is also indisputable.

The need for the changes is strictly evolutionary. The professional bodies within the professions of prosthetics and orthotics recognized the need and, indeed, the educational requirements and professional standards of certification and licensure have been steadily upgraded and continue to be. Congress also recognized the need and passed the BIPA 2000 act in 2001 directing Medicare to allow only certified, licensed practitioners to provide prosthetic and orthotic care.

The only bodies who have not recognized the need to provide standards appear to be Medicare and the medical insurance industries.

The Evolution of Prosthetics and Orthotics:A 50-Year Perspective

John Tyo CP, BOCP, Director, Syracuse Prosthetic Center

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Engaging key referral sources and increasing your brand awareness is more important than ever. Valuable physicians can’t send you business if they don’t know who you are and the benefit of working with you to manage the care of their prosthetic patients. At OPGA, we hold the strong belief that when an independent orthotist or prosthetist enters the care continuum of a patient, the patient's health outcomes increase, and the overall cost to treat that patient decreases significantly.

We have a great story to tell, and now we have the ability to target the physicians we need to grow our practices and help more patients.

Contact OPGA for more information about the VGM Market Data program, or visit www.vgmmarketdata.com.

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Severe contractures of the fingers, elbow and knee can be very difficult to reverse with orthotic therapy. The use of pneumatic air bladder technology provides a very useful mechanism to easily apply an orthotic device and, using inflation of strategically placed air bladders, to initiate gentle low load prolonged stretch (LLPS) to reverse adaptive tissue shortening. Pneumatic air bladder braces are also effective in treating contractures with spasticity as the air bladders will "give" with involuntary muscle contractions while maintaining neuro-inhibiting gentle tension to manage the spasticity.

Severe contractures can be difficult and uncomfortable to extend with manual stretching to apply an orthotic device. The benefit of using pneumatic air is that the joint(s) is slowly and comfortably extended after the brace is applied using gentle air bladder inflation. This greatly facilitates brace donning and doffing and increases patient compliance.

The use of Air Pro™ technology eliminates the need for frequent modification of a device to maintain effective stretch. Because it is the air inflation that provides the therapeutic stretch, brace modification due to joint alignment changes is not necessary to maintain brace performance.

The AirPro™ Graduate has a detachable palmar cone that can be easily inserted into a fisted hand when deflated. The air bladder, when inserted into the fist, is slowly inflated to provide a gentle stretch on the fingers and the thumb. The neoprene air bladder, when inflated, finds the path of least resistance applying equivalent pressure on all of the contracted fingers.

The AirPro™ Graduate will incrementally open a fisted hand to better than 90 degrees at the MCP and PIP joints. With routine use, incremental ROM gains of 5 to 10 degrees per month on the fingers and thumb should be expected.The detachable "bend to fit" wrist I forearm support can be hook and loop attached to the palmar cone to support the wrist. HCPCS L3807.

The AirPro™ Grip is a one-piece WHFO with the palmar air bladder permanently attached to the wrist I forearm support. This design is best used to treat PIP flexion contractures of 90 degrees or more with minimal MCP contracture. The one-piece design helps to maintain the palmar air bladder in place when used to reverse PIP contractures. The "bend to fit" wrist I forearm support maintains optimal extension of the wrist. HCPCS L3807.

The AirPro™ Elbow is excellent for treating elbow contractures of 90 degrees or more. An air bladder on the volar side of the brace is inflated to gently extend the elbow and

provide a gentle therapeutic stretch. The brace will reverse the contracture incrementally over time to approximately 20 degrees of flexion.

By John Kenney, BOCO, Ongoing Care Solutions

Using Pneumatic Air Braces to ReverseModerate to Severe Contractures

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The brace can be applied with the elbow significantly flexed. By inflating the air bladder after application, the brace will lengthen to the optimal extended setting. HCPCS L3760.

The OCSI Static Air Knee utilizes AirPro brace technology to provide effective therapeutic stretching of a severely contracted knee (90 degrees or more) to reverse the contracture. The OCSI Static Air Knee is also effective for managing knee contractures of bed-bound patients where comfort as well as orthotic therapy are desired in knee contractures of 30 degrees or more. The brace can be applied with the knee flexed. Inflating the air bladders will extend the knee and initiate a gentle stretch to reverse the contracture. The OCSI Static Air Knee is HCPCS coded L1831, a reimbursable code for Medicare patients.

OPGA is pleased to announce a new partnership with KT Health, makers of KT TAPE.

KT Health is a privately held company based in Utah that designs, develops and distributes sports medicine products. These products keep athletes healthy, empowering all to play with confidence and to reach their peak performance.

KT Health products are distributed worldwide to individuals, medical professionals and teams through major retailers, specialty sports stores, and medical and team distributors.

Built for performance, the KT TAPE brand is KT Health’s’ featured product line that is quickly becoming the favorite accessory of

athletes in every sport. Just recently, KT TAPE was named the official kinesiology tape of the U.S. Olympic Team. KT Health is focused on innovation, quality and customer service. We look forward to working with OPGA Members to make sure that every experience with the company and its products is exceptional, both in patient results and education/service provided the clinician.

For more information, including exclusive offers to OPGA Members, please call Mat Pentelute at 801-494-6240.

OPGA Announces New Partnership with KT Health, Makers of KT TAPE

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FOLLOW OPGA ONLINE!

ADVANCING THE PROFESSION!

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