AOPA sues over audit practices

ALEXANDRIA, Va. - Saying it had run out of options, the American Orthotics and Prosthetics Association (AOPA) in May sued CMS over its auditing practices.

“We have tried to work with the agency for 18 months,” said Tom Fise, executive director of AOPA. “There was no recognition on the part of the agency that they are putting people out of business.”

The dispute has its roots in an August 2011 report from the Office of Inspector General (OIG) alleging fraud in the O&P field—something stakeholders vigorously dispute.

At about the same time, CMS also circulated a “Dear Physician” letter that dramatically changed the standards for approving a prosthetic claim by disregarding the prosthetist's notes as part of the medical record. Auditors have been applying the new standards retroactively.

The lawsuit seeks, among other things, for CMS to declare that the “Dear Physician” letter is invalid; allow prosthetic claims to be processed without requiring the prosthetist records to be supported by physician records; and reopen and reprocess all claims that were denied because they didn't meet the requirements in the letter.

CMS needs to follow procedures for notice and comment rulemaking when it makes major changes, say stakeholders.

“They can't just go and change things midstream on a whim,” said Fise.