WASHINGTON – Today, U.S. Sens. Mark R. Warner (D-VA) and Steve Daines (R-MT), members of the Senate Finance Committee, introduced legislation to improve orthotic and prosthesis care for seniors with Medicare health coverage. The Medicare Orthotics and Prosthetics Patient-Centered Care Act would make sure Medicare patients continue to have access to safe orthosis or prosthesis care through healthcare specialists while helping to reduce government fraud and waste.
“Under current law, the provision of highly specialized orthotic and prosthetic care is improperly regulated in the same way as durable medical equipment (DME), which does not reflect the service our seniors receive under the Medicare program,” said Sen. Warner. “This commonsense legislation redesigns the way Medicare delivers orthotic and prosthetic care to ensure seniors have safe access to the care they need without adding any additional cost to the Medicare program.”
The majority of orthoses and prostheses are custom fabricated or custom fitted and require the expertise of a certified or licensed orthotist or prosthetist. However, under existing Centers of Medicaid Services (CMS) regulation, these highly trained practitioners are unfairly treated in the same manner as durable medical equipment (DME). The Medicare Orthotics and Prosthetics Patient-Centered Care Act protects patients by differentiating the clinical, service-oriented manner in which orthoses and limb prostheses are provided in contrast to DME, a commodity that is not service-oriented.
Specifically, the Medicare Orthotics and Prosthetics Patient-Centered Care Act would:
- Create separate statutory requirements for the provision of orthoses and prostheses to reflect the distinction between the clinical, service-oriented nature of orthotics and prosthetics care and the commodity-based nature of DME.
- Restore Congress’ intended meaning of the term “minimal self-adjustment,” to more clearly define off-the-shelf orthoses that subject to Centers for Medicare and Medicaid Services’ competitive bidding program.
- Ensure that patients have access to the full range of orthotic care from one orthotic/prosthetic practitioner rather than requiring patients to visit multiple providers in the case where the treating orthotist or prosthetist does not have a competitive bidding contract.
- Prohibit the practice of “drop shipping” – shipping a custom orthoses and prostheses to Medicare beneficiaries without the involvement of a clinically-trained specialist – and prohibit drop shipment of off-the-shelf orthoses.
In a report to Congress, prohibiting the practice of “drop shipping” would help reduce the likelihood of Medicare waste, fraud, and abuse of orthotics and prosthetic benefits by operators of late-night advertisements and telemedicine companies. Just last year, the Department of Justice revealed a $1.2 billion telemedicine scam targeting orthotic and prosthetic beneficiaries.
In addition to Sens. Warner and Daines, the legislation is sponsored by Sen. Tammy Duckworth (D-IL), Bill Cassidy (R-LA), and John Cornyn (R-TX). Companion legislation was also introduced in the House of Representatives by Reps. Mike Thompson (D-CA), Glenn Thompson (R-PA), and G.K. Butterfield (D-NC).
This legislation has the support of Virginia Prosthetics & Orthotics and the American Orthotic and Prosthetic Association (AOPA).
“Distinguishing Orthotics and Prosthetics from Durable Medical Equipment is the most pressing issue in my profession. The provision of orthotic and prosthetic care includes a professional service component that is simply not the same as DME. The majority of orthoses and prostheses are custom –fabricated or custom-fit and require the expertise of a licensed and certified orthoptist or prosthetist whom must earn a Master’s of Science degree(s) and complete a clinical residency before becoming certified and/or licensed practitioners. Simply put, there is a great deal- sometimes years- of personalized patient care provided by orthotists and prosthetists, and lumping them into DME makes little sense,” said J. Douglas Call, CP, President of Virginia Prosthetics & Orthotics. “I also appreciate Sen Warner’s efforts to reduce Medicare waste, fraud and abuse in the orthotic and prosthetic benefit by banning “drop-shipping” of orthotics. Recently, in the midst of the pandemic, some bad actors have been charged with submitting false and fraudulent claims to Medicare for orthotic braces that were medically unnecessary, ineligible for Medicare reimbursement or not provided as represented. This hurts our profession, but more importantly it hurts patients and must be stopped.”
“The provision of orthotics and prosthetics care requires clinical services provided by highly trained practitioners. Currently, it is unfairly regulated through a DME lens instead of the clinical care lens,” said Jeff Lutz, CPO, President of the American Orthotic and Prosthetic Association (AOPA). “By differentiating the clinical care in which orthoses and limb prostheses are provided from the provision of durable medical equipment, this important legislation will ensure patients get the safe, quality care they deserve.”
Full text of the bill can be found here.