New Law Could Be Game Changer For O&P

Published in Orthotics & Prosthetics on November 13, 2023

New Law Could Be Game Changer for O&P This article was originally featured in HME News.

The orthotics and prosthetics market received a positive boost from the passage of the Lymphedema Treatment Act (LTA) earlier this year and field specialists are optimistic it will benefit providers and patients.

Set to go into effect Jan. 1, 2024, the LTA allows for consistent Medicare coverage and reimbursement for compression garments and supplies for patients living with lymphedema. This new law could be a game changer for the industry, said Matthew Gruskin, COO for Owings Mills, Md.-based Board of Certification/ Accreditation.

“As we wait for the final rule on LTA implementation specifics, BOC is encouraged that CMS will establish a new product category for compression garment and supply billing,” he said. “It will be interesting to see the extent of the patient demand – this has the potential to open the door for new referral sources for DMEPOS providers. It also means there will be more opportunities for compression fitters and for health care professionals interested in expanding their education and skill set to include compression therapy.”

Opportunities presented by the LTA may also include significant new business and revenue for mastectomy fitters, Gruskin said.

“Many mastectomy boutiques treat patients who are living with lymphedema, and the LTA could allow them to expand their reimbursable product categories with new compression garments and supplies that will be billable to CMS,” he said.

Adam Miller, president of Waterloo, Iowa-based Orthotic and Prosthetic Group of America (OPGA), a division of VGM, is also encouraged by LTA’s potential impact on the O&P market and beyond.

“LTA provides coverage for a proven product where there was no prior Medicare billable,” he said. “Providers can look to lymphedema treatment as an additional revenue stream, and it gives another billable service for providers to utilize for both patient base and referral sources.”

The LTA “is something that has been needed for a long time,” said Stephen O’Hare, president of Marietta, Ga.-based Pedors Shoes, which specializes in footwear for lymphedema patients.

“Any compression device that enables the patient to be more mobile only improves the overall health of the patient and is a health care cost-saving initiative,” he said. “The LTA should help improve access to care for patients with lymphedema that desperately need it.”

Challenges & Opportunities

Even with the anticipated reimbursement boost for compression products, the overall reimbursement rate for the O&P market continues to be insufficient, Miller and O’Hare said.

“The continuing challenges in the O&P market are very similar to HME – declining reimbursements, consolidation, hiring and retaining skilled professionals, and supply chain disruption to the availability and price of products,” Miller said.

Added O’Hare: “I think that, with the cost of literally everything going up so much over the past 18 months, reimbursement rates are so far behind the actual cost of goods and services that many providers are struggling to break even and are having to evaluate and embrace other revenue streams.”

Supply chain issues remain a challenge for the market, which still hasn’t recovered to the point where supply and demand are optimal.

“This obviously impacts workflow as it relates to the length of time to provide goods and completion of services,” O’Hare said. “I also think that the labor shortage and the cost of labor is a significant challenge for all businesses. Overly burdensome documentation only adds expense and time.”

In seeking a competitive advantage, O’Hare and Miller recommend providers adopt a more clinical focus.

“Most O&P devices that are billed to Medicare have to be fitted by ‘qualified providers,'” O’Hare said. “Additionally, some over-the-counter, Class 1 or non-custom devices can be presented as private pay items.”

Innovation & Impact

Within O&P, a category that’s ripe for new technology developments is post-mastectomy products, Gruskin says. The Breast Cancer Patient Equity Act was reintroduced in Congress earlier this summer and, if passed, the bill would provide Medicare coverage for custom breast prostheses to breast cancer survivors.

“Currently, a custom breast prosthesis is the only prosthetic device not covered by Medicare,” Gruskin said. “This legislation would allow thousands of women to access custom products following a mastectomy.”

Miller points to advances in 3D printing, robotics, AI, data collection and analytics, and customer service as areas where technology is having an impact on the market.

“The technological future is bright for O&P,” he said. “Embracing new technologies will lead to quicker, more efficient business operations and, ultimately, the goal for all of us: better patient care.”

TAGS