VA revamps how it pays community O&P providers: what AOPA's new FAQ explains

The American Orthotic and Prosthetic Association published a FAQ document this week answering questions from community O&P providers about the Department of Veterans Affairs’ new payment rules. Those rules, issued in June, changed how the VA pays prosthetists and orthotists who serve veterans outside the VA’s own facilities.

The June policy covered three categories of care that had been poorly defined in community contracts: not otherwise classified (NOC) codes, pedorthic services, and a set of Healthcare Common Procedure Coding System codes the VA itself acknowledged aren’t adequately priced under the current Medicare fee schedule. The FAQ is AOPA’s first official walkthrough of the transition for those areas.

What changed

Under the new structure, NOC codes and products the VA considers “outliers” will be reimbursed on a sliding scale tied to the manufacturer’s invoice plus a designated markup. For services that fall within the Medicare fee schedule, the VA will reimburse community providers at 100 percent of the Medicare rate, without requiring the negotiated discounts some VISNs had imposed under prior contracts.

The 100 percent Medicare rate is a departure from a patchwork of regional arrangements, where community care terms varied by VISN. The new policy standardizes reimbursement across all Veterans Integrated Service Networks.

Transition terms for providers

The FAQ lays out two paths for community O&P providers currently under VA contracts.

Existing contracted vendors can terminate their current agreements early to join the new community-based provider program. Alternatively, they can continue operating under existing contracts until those agreements expire. Blanket purchase agreements follow the same terms.

Going forward, the community-based care model replaces all new contracts. Providers who want to keep serving veterans under VA coverage will need to meet revised standards. AOPA described the overall framework as intended to create “consistent policy across the entirety of the VISNs” and “collaborative relationships” between community O&P providers and the VA.

What this means for veterans

If you receive O&P care through a community provider and your coverage runs through VA community care, your provider is currently deciding which transition path to take. Either path keeps them eligible to continue serving you, provided they meet the revised standards.

The 100 percent Medicare reimbursement removes a structural friction that had made VA community care financially unattractive for some providers. Whether that translates to better access or shorter waits in any specific region will take time to assess.

AOPA said it will continue working with its VISN liaisons to monitor how the changes land and is collecting feedback from members.

Questions worth asking your community provider

If your prosthetist or orthotist works with you under VA community care, these are reasonable things to clarify at your next appointment:

• Are you currently contracted with the VA for community care?
• Do you plan to opt into the new community-based provider program now, or continue under your existing contract?
• Are there any changes I should expect to how my VA coverage processes through your practice?
• What are the revised standards, and have you already met them?

If you’re a veteran navigating VA community care, your VA care coordinator can also explain how providers in your VISN are handling the transition. The AOPA FAQ document is available through AOPA’s member resources.

This article is based on AOPA’s FAQ document and the O&P EDGE report. It does not constitute legal, benefits, or insurance advice. Veterans with questions about their specific coverage should contact their VA care team or a Veterans Service Organization.