Medicare beneficiaries who require orthotics or prosthetics devices could find it easier to access care while being better protected from fraud if APTA-supported legislation now on Capitol Hill makes its way into law. In addition to sparing patients from being required to see multiple providers and prohibiting direct-to-consumer "drop shipping," the bipartisan bills, introduced in both the U.S. Senate and House of Representatives, would also make it easier for beneficiaries to receive replacement devices when they need them.
Known as the Medicare Orthotics and Prosthetics Patient-Centered Care Act (SB 3977; H.R. 5315), the legislation is designed to eliminate loopholes and burdensome regulations that make it more difficult — and riskier — for patients to acquire needed equipment. The Senate version of the bill was introduced by Mark Warner, D-Va., and Steve Daines, R-Mont. In the House, Reps. Glenn Thompson, R-Pa., Mike Thompson, D-Calif, Brett Guthrie, R-Ky., Angie Craig, D-Minn., and Pete Sessions, R-Texas, introduced the measure. The House version has an additional 37 cosponsors.
Among the major provisions in the legislation:
Greater availability of replacement devices. Medicare would no longer be permitted to deny coverage of replacement orthotics within what it deems the device's "reasonable use lifetime"—even if the device is damaged or a patient's needs change. These restrictions currently force Medicare beneficiaries to wait for a period of time, often five years, before they are eligible for Medicare coverage of a replacement orthosis. Instead, Medicare would be required to pay for the replacement, providing the patient meets certain conditions.
Easier access to O&P care. Under the proposed legislation, the exemption in statute from competitive bidding would be expanded to include for physical therapists, occupational therapy therapists, and orthotists and prosthetists when providing off-the-shelf orthoses to Medicare beneficiaries, allowing these providers to furnish those types of orthoses without a competitive bidding contract.
The elimination of "drop shipping." Current Medicare provisions allow reimbursement for direct-to-consumer shipping of orthoses and prostheses without any clinical intervention by a qualified provider, such as a physical therapist. The loophole leaves consumers vulnerable to fraud and creates more waste within the Medicare system. If passed into the law, the legislation would eliminate this option.
"The Medicare Orthotics and Prosthetics Patient-Centered Care Act lives up to its name by truly shifting the focus to the patient, both in terms of access and protections," said Justin Elliott, APTA vice president of government affairs. "APTA stands in strong support of this bipartisan effort, and is grateful to the Senators and House members who introduced these much-needed changes." APTA urges members to voice their support for the bill by way of the APTA Legislative Action Center.
The bill's Senate introduction in late March, just before the start of National Limb Loss and Limb Difference Awareness Month in April, also helped to draw attention to the needs of Americans living with limb loss and difference. APTA supports the role of PTs and PTAs who provide care to this population through the association's own work as well as the efforts of the Amputee Coalition, where APTA CEO Justin Moore, PT, DPT serves on the organization's board of directors.