CMS Accepting Comments for Proposed Competitive Bidding OTS Spine and Knee Orthoses

Published in Orthotics & Prosthetics on December 06, 2018

The Centers for Medicare and Medicaid Services (CMS) is soliciting comments on the agency’s proposal to include off-the-shelf spinal orthoses and off-the-shelf knee orthoses in the next round of competitive bidding. The proposal includes a total of 24 codes being phased into the next bidding program. The full list is accessible by clicking here. With the expected two-year gap in the bidding program, new contracts would not begin until 2021, with a detailed announcement expected Spring 2019. There are major concerns with patients being restricted to contracted suppliers given the instability that the program has caused within the DMEPOS industry. Providing real examples of patient concerns, practitioners can effectively demonstrate the need to keep these product categories out of the competitive bidding program.

The implications of possible reimbursement reductions beyond the Medicare program could negatively affect several payers for pediatric and adult populations. This may serve as a guide for practitioners to construct individual talking points in their submission to CMS.

Talking Points

Effective comments must focus on potential beneficiary impacts that could harm this highly vulnerable patient population.

  • Orthoses requires clinical expertise to properly fit each patient.

In order to maximize positive patient outcomes, it takes the knowledge and expertise of a certified practitioner to fit a patient with the proper orthoses. In the case of spinal and knee orthoses, without proper education from a certified practitioner, the chances of injury or improper use of the orthoses is much higher. Reducing the number of qualified practitioners who may provide the necessary patient education and proper orthoses will not improve patient outcomes. Properly fitting a patient with any orthoses requires knowledge which practitioners invest substantial time and financial resources to on an annual basis. Reducing reimbursement, too, dramatically will force practitioners to choose least costly alternatives that may not address all of a patient’s needs, again not maximizing outcomes.

  • Competitively bidding orthoses will not dramatically reduce fraud and abuse of the program.

As one industry stakeholder reports, traditional O&P practitioners are responsible for less than 15% of the total claims submitted to Medicare for the codes proposed in this rule. There is a distinct difference between mail-order suppliers driving much of the increases in utilization and abuse of the program and the certified practitioners delivering care directly to the patient. The stringent documentation requirements for practitioners already work to protect the safety of the patient and prevent abuse of the Medicare program. Mail-order bracing allows for wide-spread marketing tactics leading to abuse of the program, but this should not come at the cost of in-person, hands-on care of beneficiaries utilizing local practitioners. If CMS is going to include OTS spinal and knee orthoses, direct-to-patient practitioners must be exempt from this program in the same way that physicians and hospitals are exempt from some competitive bidding requirements. This would address the extreme growth in utilization found by the Office of Inspector General (OIG) primarily driven by several mail-order suppliers, while protecting access and freedom of choice for beneficiaries using a qualified local practitioner.

Be thorough and concise in comments using real examples to highlight the potential problems with orthoses being included in the program.

Any questions may be directed towards the VGM Government Relations team at 855-345-3469.

Comments may be submitted to [email protected] by Monday, Dec. 17 with the subject line “Competitive Bidding Product Categories.”

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