October 2013

Study finds certified providers receive only a third of Medicare O&P payments

Unlicensed providers continue to receive unauthorized payments for O&P services from the Centers for Medicare & Medicaid Services (CMS), according to a study released in September.

The American Orthotic and Prosthetic Association (AOPA) commissioned Vienna, VA, healthcare consulting firm Dobson DaVanzo to analyze Medi­care claims data from 2007 through 2011 and compare them with 2001-2006 data.

According to the report, about one third of the $3.62 billion CMS paid between 2007-2011 for O&P services went to unlicensed providers (14 states have licensure requirements) and practitioners who don’t meet accreditation requirements legislated by Congress in 2000.

Physicians provided an additional one third of these services, while O&P practitioners provided the remaining third.

Report author Allen Dobson, PhD, said, “Our analytic results are consistent with the results of a third party independent survey that confirmed that noncertified providers are continuing to provide O&P services to Medicare beneficiaries as recently as in 2013.”

In related news, Noridian Healthcare Solutions, Medicare’s durable medical equipment pricing, data analysis, and coding (PDAC) contractor, released data in July showing its seventh quarter prepayment review of claims for ankle foot orthoses (AFOs) and therapeutic shoes for people with diabetes found extremely high error and denial rates of 99% and 85%, respectively.

Claims for diabetic shoes were denied because they lacked appropriate documentation, including patients’ medical histories and evidence of a diabetes care plan and in-person foot exams and therapeutic shoe measurements. More than a quarter of claims for AFOs were denied because physicians failed to file documentation detailing the medical necessity for custom rather than prefabricated AFOs, and another 21% were denied because patients didn’t meet Medicare criteria for custom AFOs.

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