OIG: CMS pays too much for braces

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Wednesday, December 19, 2012

WASHINGTON – The Office of Inspector General (OIG) recommends in a new report that CMS lower the fee schedule amount for certain back braces through competitive bidding or inherent reasonableness.

Medicare paid more than $96 million for L0631 back orthoses in 2011, nearly four times what providers paid to acquire them. Between July 1, 2010, and June 30, 2011, the average Medicare allowable for the orthoses was $919; the average supplier acquisition cost was $191, according to the report.

The OIG also found that, although the code description for L0631 includes fitting and adjustment services, one-third of providers reported they did not provide those services. The remaining two-thirds of providers reported providing services that ranged from taking measurements to adjusting the brace for fit.

While CMS agrees that the fee schedule amount for L0631 should be adjusted, it does not agree with using inherent reasonableness.

CMS may be more amenable, however, to including the code in competitive bidding. The agency in February included L0631 in a proposed list of off-the-shelf orthotics that could eventually be included in the program. CMS is still in the process of finalizing the list after gathering feedback from stakeholders.

[See also: Orthotics list: ‘Double-edged sword’