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David McGill Blogger

Clarification That Confuses

Posted by David McGill | November 04, 2014

The History

In March the DME MACs issued joint guidance stating that only the following providers had the qualifications necessary to fit "custom-fit" orthoses: (1) certified orthotists; (2) physicians; (3) physical therapists; (4) occupational therapists; or (5) treating practitioners. After incorporating this guidance into the local coverage determinations for orthoses, the immediate question that arose out of this was what qualifications does someone need to be a "treating practitioner?"

In July, Medicare published a draft rule proposing that the term "qualified practitioner" applied to (a) physicians' assistants, (b) nurse practitioners, and (c) clinical nurse specialists. In response, AOPA and numerous other organizations weighed in, urging Medicare to include other kinds of providers in the definition of "qualified practitioner," such as certified orthotic fitters.

Last Friday, Medicare issued the Final Rule that we hoped would definitively clarify the issue. It did not.

The Final Rule  

Without any substantive explanation, Medicare "punted" on defining who a qualified practitioner is, instead saying only that it had "decided not to finalize any changes" proposed in the draft rule. In other words, it decided not to decide.

What does this mean for you?

From one perspective you could view Medicare's non-decision positively. All of the organizations in the O&P Alliance had concerns about the proposed language in the draft rule. So the decision not to implement a rule that everyone thought had real flaws is arguably a good thing. 

On the other hand, Medicare has left suppliers a bit adrift in terms of understanding what the current standards are for fitting custom-fit orthotics. While CMS declined to finalize any changes proposed in the draft rule, the MACs have previously incorporated their own guidance into the orthotic local coverage determinations and DMEPOS Supplier Standards. Thus, the possibility exists that even with Medicare's non-decision, the MACs' prior guidance in the LCD's and standards still remains "live." Unless Medicare issues clarifying language moving forward, the likelihood is that suppliers will have to continue delivering and billing for custom-fit orthoses without definitively understanding what the governing standards are.

We will continue to closely monitor this still-developing situation moving forward. In the meantime, we recommend that you review the orthotic LCDs to remind yourself of how the MACs have previously addressed the issue of who is qualified to fit custom-fit orthoses. 


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