How to Avoid Becoming a Victim

What to Do If You’ve Been Scammed

The U.S. Department of Health and Human Services announced last week that there is a widespread fraud scheme involving orthotic braces and other medical equipment. It is one of the largest healthcare fraud schemes ever investigated with more than $1.7 billion in fraudulent Medicare claims.

Basically, scammers are offering Medicare beneficiaries orthotic braces that are supposedly free to them. Fraudsters are calling beneficiaries and targeting them through advertisements to order the “free” braces.

THESE BRACES ARE NOT FREE. Medicare is being billed for them. And, when beneficiaries actually need braces, they’re often being denied because Medicare shows they already have received the devices. Moreover, unless fitted and prescribed by a medical professional, the braces are often ineffective. THESE ARE NOT RECOMMENDED IN ANY WAY.


  • If you receive a call offering a free brace, hang up and do not provide any information.
  • If medical device is delivered to you, do not accept it unless your physician or certified orthotist sent it to you.
  • Always be suspicious of anyone offering you free equipment and asking for your Medicare information, unless it is your medical provider.
  • Never provide your Medicare information to anyone other than your medical provider.

If you’ve been a victim and need to report the scam, please call 1-800-377-4950.





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Originally posted by Opie Choice
If you manage an orthotic and prosthetic practice, you know that the fiscal health of your business relies on effective and compliant billing. While that seems straightforward enough, the scrutiny of the Office of the Inspector General (OIG) has underlined the importance of doing things the right way, the first time, so you can get and keep your money and avoid costly audits and denials.

The simple truth is that 90 percent of denials are preventable, and 2 out of 3 denials are recoverable. I’m going to share some strategies for getting and keeping your money by successfully managing audits, denials, and appeals.

What Can We Do?


That’s obvious enough, but incredibly true. According to Haines and Morgan, 90 percent of denials are avoidable. That means that we have the power to make sure they don’t happen to us, or to our patients.

Why Do Denials Happen?

Understanding why denials happen can help us to prevent them. Most denials occur because of the following:

  • Ineligible/Uncovered Services
  • Failure to Obtain Prior Authorization
  • Lack of Proven Medical Necessity
    • Medical Records
      • Diagnosis
  • Incomplete or Inaccurate Patient Demographic Information
  • Service Covered by Another Plan/Payer

How Can We Prevent Denials?

Now that we know the basis for most denials, we can see that prevention is in the hands of your entire office. Right now we will focus on how the front office can work effectively to prevent denials. Investing in your billing practices will save time- and money- in the long run. These should be a mainstay in your front office procedures:

  • Thorough Patient Intake and Accurate Data Entry
  • Insurance Verification and Prior Authorization
  • Obtaining External Medical Records for Patients
  • Ensuring Clinical Documentation is Complete and Compliant
  • Scrubbing the Bill/Claim Prior to Submittal

What Should We Do if We Are Audited?

Audits happen. The most important thing for you to do is not to panic and to make sure you follow these steps:

  • Respond in a Timely Manner
  • Do NOT Fail to Respond (even if the amount is low, you do not want an error on record)
  • Be Polite
  • Keep Track of ALL Correspondence
  • Thoroughly Respond to the Request
  • Do NOT Alter Records in ANY Way
  • Request “Return Receipt” When You Send Records
  • Ask when You Will Receive a Response

What About Appeals?

If your claim is denied outright or after an audit process, and you disagree with the findings, you can issue an appeal. Remember, 2 out of 3 denials are recoverable. That’s because the denial is usually based on incorrect or incomplete information. The appeal is your opportunity to make things right. Not only is it generally in the patient’s best interest, it will also help you tighten your own processes and, quite possibly, receive the funds you’re hoping for.

What’s the Bottom Line?

While it’s true that O & P practices are subject to denials and audits now more than ever, it’s also true that we have the power to get and keep our money through solid front office/billing procedures and proper management of audits and appeals.


Originally posted by Opie Choice

We’ve all heard, “the customer is always right” and “customer is king.” We know that good customer service is critical to our success. But, are we making it a priority? Are we doing it well? Are we effectively managing our relationships or just running ourselves ragged trying to make everyone happy? I’m going to challenge you to rethink customer service.

A reminder about why customer service is so important:

  • It is 6-7 times costlier to attract a new customer than it is to retain an existing customer.
  • It takes 12 positive customer experiences to make up for one negative experience.
  • A 10% increase in customer retention results in a 30% increase in the value of the company.

Now, let’s define true customer service. It’s not just about making your customers happy, it’s about intently managing all your relationships by identifying critical relationships, understanding expectations, avoiding conflict, and (if it happens) addressing difficult issues.


Service isn’t just directed at customers/patients. It’s about managing all our business relationships. Ask yourself: “What are my MOST critical work relationships?” You’ll probably include: patients, referral sources, vendors, insurance companies, colleagues, and community in your list. As you would expect, all of these deserve your attention!



One of my favorite quotes is, “We have to meet or exceed our CUSTOMERS’ expectations, or change  them.”  Expectations drive relationships. For successful relationships, we need to understand expectations, decide how to meet or exceed them, and when expectations are unreasonable, change them.

Identifying expectations is tricky. We know there are basic expectations: integrity, politeness, honesty, etc. And then, there are those unique to each individual and situation. It’s vital we set a good example by communicating our expectations and creating a forum for others to do the same. If we know where the goal post is, we are more likely to reach it. And, if we find it’s 100 miles past where we’re willing to go, we need to redefine the relationship.


Conflict is costly. So, avoiding it should always be our aim. We can do that through: listening, clarifying the issues, being thorough in intake and follow through, and taking time to communicate. Basically, be clear about what you need/intend to do, do what you said you would, and follow through so those affected know what you did.



Despite our best efforts, conflict happens.  I rely on the PRESTO process: Prepare, Relate, Explore Interests, Suggest Option, Tailor Agreement, Operationalize. When communicating with someone with whom there’s a conflict, I prepare by understanding the situation. I try to understand the other person’s position. I explore our interests to see if we can find a mutual solution. I create an agreement by which we can both abide. Finally, I determine if there’s something about the process that needs to change to avoid future conflicts. Learning from mistakes often means making changes.

Customer service is a process. It’s an everyday endeavor that requires us to focus on all of our important relationships. It takes effort, but it’s ultimately worth it.

Together, we can build a better practice.



Originally posted by Cascade Ortho

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 anew card 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 15th, 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.


Our friends at Ossur recently made us aware of three new audit issues, approved by Performant Recovery, which affect Complex Spinal Orthoses, Complex Medical Necessity AFO & KAFO Orthoses, and DME Billed While Inpatient. According to the statement from Ossur, here’s what you need to know:

Complex Spinal Orthoses

Documentation will be reviewed to determine if Spinal Orthoses meet Medicare coverage criteria and/or is medically reasonable and necessary. Affected Codes: L0452, L0480, L0482, L0484, L0486, L0629, L0632, L0634, L0636, L0638, L0640, A9270.

Complex Medical Necessity AFO & KAFO Orthoses

Medical documentation will be reviewed to determine that services were reasonable and necessary. Affected codes: L1900, L1904, L1907, L1920, L1940, L1945, L1950, L1960, L1970, L1980, L1990, L2106, L2108, L4631, L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2126, L2128

DME Billed While Inpatient

A supplier may deliver a DMEPOS item to a patient in a hospital or nursing facility for fitting or training the patient in the proper use of the item. This may be done up to two (2) days prior to the patient’s anticipated discharge to their home. The supplier should bill the date of service on the claim as the date of discharge and shall use the place of service (POS) as 12 (patient’s home). The item must be for subsequent use in the patient’s home.

To ensure compliance and prepare for any audit issues, please review the medical necessity for braces and make sure you have the proper physician’s documentation. Also, as Ossur advises, if you do receive an Additional Documentation Request (ADR) from Performant, be sure to respond with all of the required documentation.

If you need help better understanding audit issues, if your practice is in compliance, or how to deal with an ADR, please contact O&P Insight today and let us help!


The Centers for Medicaid and Medicare Services (CMS) recently announced to all Medicare Fee-For-Service providers that it is planning to  assign new numbers (known as Medicare Beneficiary Identifiers or MBIs) and issue new Medicare cards to all people with Medicare beginning in April 2018.

The transition to MBIs, according to CMS, is about complying with the law in protecting patients’ social security information. The MBIs will replace the current Health Insurance Claim Number (HICN) on the new Medicare cards. The hope is that this step will protect people with Medicare from fradulent use of Social Security numbers, which can lead to identity theft and illegal use of Medicare benefits. All current cards will be replaced by April 2019.

You’ll need to prepare your systems and business processes to accept the new MBIs as they are being mailed out to patients beginning in April 2018. There will be a transition period, where you can use either the HICN or the MBI to exchange data and information with CMS. This transition period will commence April 1, 2018 and continue through December 31, 2019.  You’ll want to be ready for the MBIs by April 1, 2018, though, because new Medicare patients will only receive the MBIs, not the HICN.

You may need to change your systems to accept the new MBI, identify patients who qualify for Medicare under the Railroad Retirement Board (RRB), update patient numbers to automatically accept the MBI from the remittance advice transaction, educate your vendors, and ensure your patients’ addresses are up to date to ensure they’ll receive their new Medicare cards in the mail.

Be on the lookout for the letter that you received from CMS, which looks like THIS. It contains specific information about your MAC.

For a full list of facts and information to help you prepare, please CLICK HERE.

IF you need help guiding your practice through this process, please don’t hesitate to contact O&P Insight. We have the expertise to help this be a seamless transition for you!