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VOL. 124 | NO. 98 | Wednesday, May 20, 2009

Artificial Limb and Brace Fitters Under Greater Scrutiny

By Tom Wilemon

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“It’s absolutely imperative that we protect the patient from unscrupulous and unqualified practitioners. I’m very thankful that Tennessee is a licensure state.”
– James P. Rogers
President, American Academy of Orthotists and Prosthetists

State and national regulators are putting the fitters of artificial limbs and body braces under greater scrutiny because of fraud and an increased demand for services.

James P. Rogers of Chattanooga, president of the American Academy of Orthotists and Prosthetists, welcomes the scrutiny. The public needs to be protected from unqualified and unscrupulous individuals, he said, as the devices become more complex. Wars in Afghanistan and Iraq, an aging population and high rates of diabetes are causing more people to need prosthetics (artificial limbs) and orthotics (braces).

“This is not some 1950s brace anymore,” Rogers said. “It’s a very specific science that requires a unique component of skills: biomechanical knowledge and engineering knowledge, the specific knowledge of the components we have available to us and then the knowledge of what components are most appropriate together to meet the function need.”

Credentials, if you please

For decades, both have been allied health professions with no licensing requirements.

In January 2008, Tennessee became one of only 14 states to require licensure.

Ted Snell of Memphis, owner of CFI Prosthetics & Orthotics, lobbied for the legislation. His family has been in the practice for five generations, dating back to 1911. Whereas his predecessors worked with wooden legs, Snell was helping someone use microprocessor knee technology this week.

The rapid state of evolution in new technologies requires personnel who know what they’re doing, Snell said.

There also has been action on the national front in recent years. Congress in 2001 mandated that the Centers for Medicare & Medicaid Services determine who is qualified to receive payment for such services. Last October, the agency set quality standards for suppliers of the custom-fitted devices and is setting further guidelines.

Federal prosecutors are cracking down on fraud. Last July, Gustavo Smith, owner of Miami-based firms Medstar Services and Orthotics Fitters of Miami, was sentenced to more than 10 years in prison for submitting more than $4.6 million in fraudulent Medicare claims.

Earlier this year in Texas, prosecutors presented evidence that led to the indictments of the owners of two companies, Orthopedic Specialists DME Inc. and San Antonio Orthotics and Artificial Limbs, for alleged fraud.

Last October, the U.S. House of Representatives Subcommittee on Contracting & Technology held hearings to learn about the companies that contract with Veterans Administration hospitals to provide prosthetic devices.

Rogers testified before the subcommittee and noted the VA contracted only with firms accredited by the American Board for Certification in Orthotics, Prosthetics and Pedorthics (devices fitted below the ankle).

“As new technology has advanced our field, we continue to upgrade the curriculum in our education programs and even the way in which we educate people,” Rogers said in prepared comments. “Today, the profession is committed to making a master’s degree the requirement to enter the field.”

He outlined the continuing education program by the academy and other professional associations.

Toward scruples

In Tennessee, not all orthotists and prosethetists have degrees in the profession, but many do have years of experience to compensate. Elizabeth L. Miller, the director of Health Related Boards for the state of Tennessee, said the legislation allowed these practitioners to be grandfathered.

“It grandfathered in those who had been practicing for five years and said that until Jan. 1, 2008, a person certified in orthotics and prosthetics or a person certified in pedorthics could apply for and be granted licensure upon payment of the fee. If they waited until after Jan. 1, 2008, then they had to meet the requirements for licensure, including taking the exam and meeting the educational requirements.”

States have been slow to establish licensure procedures for a variety of reasons, Rogers said. The number of practitioners is small and specialized compared to other health care fields. The devices did not start becoming complex until after World War II.

In more recent years, disagreements between associations representing physical therapists, orthotists and the manufacturerers of orthotic devices have made it difficult to reach consensus, Rogers said.

Also, the work of physical therapists and orthotists overlaps, he said. Orthotic device manufacturers often bypass orthotists and sell their products directly to doctors’ offices.

Edward Correia, a Washington, D.C, attorney for the National Orthotics Manufacturers Association, explained the organization’s stance.

“NOMA has not opposed licensure effort in general,” he said. “The issue is that manufacturers make knee brace and other devices, which can be fitted in a

doctor’s office. When they do that, the patient can go in and get measured and checked right there under the doctor’s supervision.

“When these licensure statutes have come up, what NOMA has argued is those trade representatives who go in there and actually perform fairly simple tasks of measuring and fitting should be able to do that under the doctor’s supervision.”

Orthotists and prosthetists often have to make customized devices.

“It’s absolutely imperative that we protect the patient from unscrupulous and unqualified practitioners,” Rogers said. “I’m very thankful that Tennessee is a licensure state.”

Looking ahead, the next push is for parity legislation that would require private insurance companies to cover the costs of prosthetic devices. Snell, who is the former president of the American Orthotic & Prosthetic Association, said he hopes that the Tennessee Legislature will pass a law next year.

“There are amputees who come in here today and think they have insurance that will pay for prosthetics,” Snell said. “As we get into checking policies, we find out they don’t have coverage or a very limited amount.”

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