Three CMS decisions moving right now while Congress campaigns

Congress is in recess, campaigning for the November midterms. CMS is not.

The National Association for the Advancement of Orthotics and Prosthetics released its October policy webcast this week, with attorney Peter Thomas, JD, running through several active CMS workstreams affecting O&P access. Three of them matter directly for prosthetics users.

Upper-limb coding: a work group that went sideways

The effort to modernize the upper-limb prosthetic coding system through the Healthcare Common Procedure Coding System Work Group was supposed to update how CMS classifies and reimburses contemporary prostheses. NAAOP, the American Academy of Orthotists and Prosthetists’ Upper Limb Prosthetic Society, and the O&P Alliance have been working on it for years.

The results so far are not what they pushed for. Thomas said CMS merged multiple technologies into single codes and set reimbursement levels that prevent patient access to contemporary partial hand and finger prostheses. In practice, a provider may not be able to stock or offer an updated partial-hand device and get reimbursed at a rate that covers its cost.

A preliminary hearing on some of those decisions is scheduled for early November. Thomas said a coordinated response from the field is planned.

Prior authorization: who it targets and what to ask your provider

CMS implemented a one-year prior authorization requirement for certain O&P billing codes. The requirement applies to new Medicare suppliers and to suppliers that have recently changed ownership. The stated target is fraud: CMS cited persistent abuse in the O&P benefit, primarily through off-the-shelf orthotic devices.

If your provider has operated for years under consistent ownership, this doesn’t change your experience. If you’ve recently moved or need to establish care with an unfamiliar supplier, it’s worth asking up front whether they’re subject to the prior auth requirement before scheduling a fitting appointment.

Competitive bidding: the two exemptions the field is asking for

CMS is also pursuing another round of competitive bidding for off-the-shelf orthotics, aimed at reducing expenditures and fraud in that segment. NAAOP and the O&P Alliance have focused their lobbying on two specific provisions: a ban on drop-shipping custom O&P devices directly to patients’ homes, and an exemption that would let certified and licensed O&P practitioners serve patients at the point of service without needing a competitive bidding contract, though at the competitive bidding rate.

The fly-in effort in July produced a bipartisan House letter to CMS administrator Mehmet Oz, MD, asking the agency to implement these two provisions under existing authority rather than waiting for the Medicare O&P Patient Centered Care Act (H.R. 4475 and S. 2329) to pass. The O&P Alliance sent a separate letter from a different angle. Both were transmitted to CMS in September.

What this means

The upper-limb coding fight is the most immediately consequential for patients. If the November hearing reverses the merged-code decisions, access to partial-hand and finger prostheses under Medicare could improve. If it doesn’t, the current reimbursement structure stays in place and continues limiting what providers can offer.

The competitive bidding provisions, if implemented, address a different problem. Custom O&P care doesn’t fit well into a drop-ship model: the fitting process normally involves a practitioner measuring, adjusting, and evaluating the device in person. The exemption for licensed practitioners preserves that process even in the absence of a competitive bidding contract.

After November, the political calculus at CMS may shift. Thomas noted that the post-election period will bring new dynamics for the O&P profession to navigate. That doesn’t change the regulatory work already in motion on any of these three fronts, but it may change how much appetite the agency has for the adjustments NAAOP is seeking.

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This article describes regulatory and policy developments as reported by NAAOP. It is not benefits, insurance, or legal advice. For questions about coverage for a specific device or claim, contact your payer or a benefits counselor.