Ortho Grows Up
by Helen M. Farrell
More sophisticated products drive payor demand for better-educated providers.
 Along with the newfound popularity of soft orthopedic goods has come increased concern over the qualifications of providers of these supplies.
During the course of the last 10 years, a quiet evolution has occurred in the soft orthopedic market. As if by magic, the old plain white boxes containing soft orthopedic products, once shoved on a shelf in the back of the HME store, have sprung to life. Soft orthopedic product manufacturers, anticipating the growth in this category, have risen to the challenge by providing new and innovative products with an eye toward attractive packaging and design. New technology, combined with strong marketing and advertising allowance programs, presents an excellent opportunity for the HME provider looking to increase sales. However, this evolution in soft orthopedic technology has not gone unnoticed. As technology expands and more products become readily available, third-party payors, physicians, industry organizations, and the Department of Health and Human Services (HHS) are recognizing the need for trained personnel to properly supply these products to the public. “The supplier who is concerned about ethical home health care delivery readily recognizes the need for education and training before they are willing to fit a patient in an orthotic appliance,” says Barbara A. Harris, director of Home Health Certification Programs for the National Community Pharmacists Association, Alexandria, Va. “We must all be concerned about liability factors; however, if your primary focus is on the patient’s well-being, then liability is not a big issue because you are going to do the right thing.” Medicare May Tighten Standards
Technological advances and the need for education and training, although slow in coming, are filtering through to Medicare reimbursement. Historically, Medicare has not required that a supplier of prosthetics or orthotics meet certification or educational requirements other than what a state may require. Fewer than 10 states have specific licensing requirements for suppliers of prosthetics and orthotics. However, this is changing. The March 22, 2002, Federal Register contained a Centers for Medicare & Medicaid Services (CMS) notice of intent to establish special payment provisions and standards for suppliers of prosthetics and certain custom-fabricated orthotics. In addition, a 1997 Office of Inspector General (OIG) report, “Medicare Orthotics” by Inspector General June Gibbs Brown recommended that standards be established and required for suppliers of custom-molded and custom-fabricated orthotics. Private Sector Leads the Way
Many private third-party payor sources already routinely require a higher standard than the certification obtained from attending a manufacturer’s training school. Fortunately, obtaining a solid educational foundation in orthotic fitting will not break the bank. At least two major manufacturers offer weeklong courses at regular intervals throughout the year. These courses are fairly inexpensive and include basic anatomy, physiology, and pathology relative to the fitting of prefabricated orthopedic appliances, as well as product selection and hands-on fitting and application. Immediately following the manufacturer’s weeklong program, both the National Community Pharmacists Association and the Board for Orthotic Certification provide the attendees with an opportunity to complete an industry certification examination. Successful completion of this test, which consists of both a practical and a written examination, allows the attendee to achieve entry-level status as a certified orthotic fitter. Continuing education credits are required to maintain certification status. “The technology is constantly changing and it is important that the fitter stay abreast of changes,” Harris says. After practicing for 3 years and fulfilling additional requirements, a certified orthotic fitter may take an examination to achieve the level of certified master orthotist. This distinction identifies the fitter as qualified to fit major orthoses. “These types of orthopedic appliances require significantly more training, especially in the areas of tracing, molding, and casting, to fit the patient properly,” Harris says. Although at this time stricter guidelines appear to be focused on prosthetics and custom-molded and custom-fabricated orthotic appliances, it takes only a small leap of the imagination to see the credentialing criteria extended to all orthotic appliances billed for insurance reimbursement. Establishing credentialing is not a bad thing. It will provide protection for patients from “over” and “under” fitting by unskilled and/or untrained fitters, and proper fitting will improve patient compliance. Awareness of the current environment geared to credentialing, coupled with recognition and acceptance of the need for education in orthotic appliance fitting, will prepare providers to enter the soft orthopedic market in a strong manner, confident that they will be successful well into the future. CPM Reimbursement Challenge | All HME providers who deal with Medicare, Medicaid, and private insurers struggle with reimbursement schedules that fail to adequately compensate them for their time and labor, as well as their equipment costs. One area where that has become evident is in the sale of continuous passive motion (CPM) machines. “The reimbursement [is] minimal and the time consumption in providing a CPM [is] maximum,” says Judy Bunn, director of compliance and education for Hamilton’s Health Aid Services, Cincinnati. The machines, which are used in the rehabilitation of joint injuries, are complex and often need adjustment or repair in the course of service—time and expense not covered by payors. Steve Barnett, vice president of Medcom Group Ltd, Johnstown, Colo, which has specialized in the distribution of CPM machines since the 1980s, says that if one of his staff spends less than 30 minutes with a patient setting up the device and explaining its operation to them and their caregiver, they “probably haven’t done the job right.” In addition, many insurance companies require follow-up visits before they will reimburse a CPM equipment provider, Bunn says. Currently, Medicare reimburses for CPM machines used to rehabilitate total knee replacements only for 21 days after surgery and then only outside a hospital setting. Treatment with the machine must start 48 hours after the surgery takes place to be eligible for coverage. The reimbursement rate is $18 to $21 per day. When making a claim, documentation regarding the type of surgery, the date it took place, and the date of discharge from the hospital must be included or the claim will be denied. The strict rules and limited reimbursement may be a function of how useful the administrators at the Centers for Medicare & Medicaid Services see CPM machines. “To me, as a legal person, I do not see the benefits of [CPM] as clearly as using a walker,” says Denise Fletcher, JD, Brown & Fortunato, Amarillo, Tex. Workers’ compensation and private insurance companies usually cover CPM machines for a wider variety of users than the government, but they are still focused on the bottom line, Barnett says. “They are for-profit and they want to make money, and they are putting the screws to the vendors and the doctors and the hospitals to accomplish that goal,” he says. There are ways to make money with CPM, Bunn says. However, increasingly these ways rely on a provider being able to build a large base of orthopedic surgeons and rehabilitation clinics that will refer their non-Medicare patients to them. However, Medcom Group, which resembles Bunn’s model, has seen its profitability erode in recent years. “Our sales volume is about the same as it has been for the last 3 years, though for the last 3 to 4 years our volume of patients has easily more than doubled, our paperwork shuffling probably trebled, and our bottom line has gotten smaller,” Barnett says. When Medcom Group first entered the market and chose to specialize in CPM, reimbursement from private insurers was straightforward. “In the old days, you sent a bill to an insurance company and as long as it was not outrageous, they paid it,” he says. As Barnett sees it, insurers need to pay claims more quickly. On average, a clean claim to a private insurer will take about 90 days or one fiscal quarter to clear, but can take as long as 2 years to clear. With all of its pitfalls, Barnett has stayed in the line for a simple reason. “It is a labor of love,” he says. —C.A. Wolski | | Helen M. Farrell is a billing consultant in Chesapeake, Va.
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