CMS Announces Proposed Rule on Orthotics and Prosthetics Qualified Providers

Feb 23

On January 11th, 2017, CMS released a proposed rule (CMS-6012-P) which would have a significant impact on eligible professionals who furnish custom-fabricated orthotics and prosthetics.  The rule, titled “Establishment of Special Payment Provisions and Requirements for Qualified Practitioners and Qualified Suppliers of Prosthetics and Custom Fabricated Orthotics,” removes exemptions to quality standards and orthotic certification for OTs and PTs, and would require licensure in orthotics, pedorthotics, or prosthetics by the state or, in states that do not provide such licensure, training and education in provision and management of orthotics, pedorthics, and prosthetics; and certification by the American Board for Certification in Orthotics, Prosthetics and Pedorthics (ABC), the Board for Orthotist/Prosthetist Certification International (BOC), or a Secretary-approved organization with standards equivalent to ABC or BOC.


Section 427 of the Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) requires that no Medicare payment shall be made for custom-fabricated orthotics or prosthetics unless furnished by a qualified practitioner and fabricated by a qualified practitioner or a qualified supplier at a facility that meets criteria the Secretary determines appropriate.  The statute also establishes requirements for both qualified suppliers and qualified practitioners.  The statute defines a qualified practitioner as a physician or other individual who is a qualified PT or OT; is licensed in orthotics or prosthetics by the State in which the item is supplied; or in states where the state does not provides such licensing, is specifically trained and educated to provide or manage the provision of prosthetics and custom-designed or fabricated orthotics AND is certified by the ABC or the BOC; OR is credentialed and approved by a program that the Health and Human Services Secretary determines has the training and education standards that are necessary to provide such prosthetics and orthotics.  A committee was established to determine how to enact the law with a deadline of one year from the date of enactment for CMS to issue regulations.  However, by 2003, the committee was unable to reach a consensus.

Furthermore, the Medicare Improvement for Patients and Providers Act of 2008 (MIPPA) stated that O&P suppliers had to show evidence of accreditation by one of the accreditation organizations.  The HHS Secretary was given the right to exempt “eligible professionals” which included qualified OTs, PTs and physicians from the quality standards and accreditation requirements.  Those exceptions have been in place since 2008.

The currently proposed rule would implement the provisions mentioned above.


CMS is proposing that qualified suppliers who bill Medicare for prosthetics and custom-fabricated orthotics would need to meet the requirements included in the final rule no later than one year after the posting date of the final quality standards or at the time of the supplier’s re-accreditation cycle, whichever is later. CMS is expecting qualified practitioners to meet the licensure and certification requirements proposed and subsequently finalized via rulemaking within one year of publication of the final rule.

The APTA, AOTA, ASHT, and Hand Therapy Certification Commission (HTCC) are working to gather information in response to the proposed rule.  CMS will accept comments on the proposed rule until March 13, 2017 and will respond to comments in a final rule.