2018 marks a year of change as Medicare and private insurance companies implement new programs and coding updates.  This will impact the orthotic and prosthetic industry in several different ways.  Specifically, changes to Medicare codes will affect current billing practices and the practice’s bottom line, while notices of change posted from private insurers will affect patient’s coverage for orthotic and prosthetic services and devices.  It is important to understand these changes so adjustments can be made to internal processes, finances, and most importantly, the patient experience.

New Medicare Cards and Numbers

The Center for Medicare & Medicaid Services (CMS) has announced that 2018 will be a transitional year for its numbering and carding system. The new system will remove patient’s Social Security Numbers from their Medicare ID and patients will be assigned a new Medicare Beneficiary Identifier (MBI).  CMS will begin replacing patient’s cards in April 2018, with hopes the transition will be complete by April 2019. All current patient numbers (or HICNs), will be completely phased out by January 1, 2020.

Transitioning to Medicare’s new MBIs will be manageable if staff members and patients are educated and internal systems are adapted.  This new system does require practices to work with billing, clearinghouses, and any other integrated vendor systems to ensure their systems can handle both HICNs and MBIs during the transition.  CMS has a lot of useful information regarding the transition on their website, which can be accessed at www.cms.gov/newcard.

New Medicare Physician Fee Schedule

CMS has released the 2018 Medicare Physician Fee Schedule which includes updated payment levels for specific codes and changes to existing codes.  Additionally, some Orthotic and Prosthetic Management and Training codes have also been effected.  The Final Rule was published after public comment on November 15^th, 2017 and additional information can be accessed by clicking here.  Be sure to be on the lookout for industry-specific summaries on how these changes will directly impact O&P practices.

Medicare Billing Code Changes

The 2018 HCPCS Codes were recently released by CMS and will have minimal impact on the O&P industry.  However, there were new codes issued, like L3761 for elbow orthoses and L7700 for a gasket or seal for use with a prosthetic socket insert.  These codes are applicable for all services provided after January 1, 2018.

Medicare’s Targeted Prove and Educate (TPE)

To cut down on improper claims, CMS utilizes Medicare Administrative Contractors (MACs), to review clinical documentation.  Through Targeted Prove and Educate (TPE), MACs focus on specific providers/suppliers and review 20-40 claims per provider, per item or service, per round, for up to three rounds of review.  After each round, providers are offered education based on the results of their reviews.  The more errors in the claim, the more rounds of review a claim is subject to.  Those who continue to have high error rates after three rounds may be referred to CMS for additional action.  Practices can counter this potential threat by being prepared, cleaning up claims processes. and conducting an internal audit with an industry advisor.  This effort will help identify ongoing issues so they can be resolved prior to an audit.

Private Insurer Notice of Change

As private insurers post their annual notice of changes in coverage, patients are seeing reduced or altered coverage.  It is critical that Practitioners advise patients (especially as they are selecting new coverage), to select a policy that includes them as a contracted provider.  Patients should also check benefit and coverage policies to make sure a particular device or their current devices are still covered.

What Should You Do

Unequivocally, the 2018 Medicare changes will impact clinics, staff, and patients.  The key to managing these changes is frequent communication. Verifying patient contact and insurance information regularly will help ensure that patients are aware of policy changes.  Kickstart the New Year by checking each patient’s information on file when they come in for an appointment.   Have them verify their address, get a copy of their insurance card, and advise them to check their Medicare address on file.  Refer to the CMS website often and subscribe to email updates.  Also, feel free to reach out to industry associations and advisors, such as Cascade and O&P Insight, to help guide you through a successful transition.

Together, we can build a better practice.

About the Author: Lesleigh Sisson, CFom, has been committed to serving the O&P community since 1992. Prior to starting O&P Insight, she served as the Director of Administration for a multi-practice company. During her experiences in administrative and clinical support roles, she recognized the need to assist dedicated professionals who want to provide excellent patient-centered care while achieving successful reimbursement. Lesleigh helps independent O&P practices to not only survive, but also thrive in today’s challenging and ever-changing healthcare environment.

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