PFA Outlines Facility Accreditation Solution Strategy to ABC and BOC
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PFA Outlines Facility Accreditation Solution Strategy to ABC and BOC

On Tuesday, February 3, PFA sent its membership an update on actions that the organization has taken on your behalf since the Centers for Medicare and Medicaid Services (CMS) rescinded thefacility accreditation exemption for pedorthists on December 8, 2008.  In the e-mail, PFA also called on its members to contact their credentialing and accrediting organization - ABC and/or BOC - to contact CMS to support the solution to the facility accreditation requirement that PFA had proposed to CMS.

Today, PFA sent a message to ABC and BOC outlining the reasoning behind this request. Following is the text of PFA's message to ABC's Cathy Carter and BOC's Greg Safko:

Cathy and Greg:

I wanted to follow up withboth of you concerning the recent blast e-mail that PFA sent to its members in order to mobilize them on the facility accreditation issue.

Back in December 2008 when CMS announced that pedorthists were no longer exempt from facility accreditation requirements (and subsequently, the exemption from the surety bond requirement), PFA began to work to determine what was going on and what we could do to reverse this action to restorea fair, level playing field to O P & P.  Given that this impacted facility accreditation, a service which both ABC and BOC provide to orthotists, prosthetists and pedorthists, along with their professional credentials, I think PFA would have expected you to at least have asked CMS why they had rescinded the pedorthic exemption rather than accepting it as a fait accompli. If the question had been asked, as PFA asked it, you would have found substantial confusion on the part of CMS.

I know that both organizations' goals are to protect the public and that you don't lobby.  However, there is a duty to protect your certificants/accreditants, as much as PFA has one to protect its membership. Your asking CMS "why" wouldn't have been making a statement as to what is right or wrong, but rather trying to determine what is correct or incorrect.

Early on, CMS indicated to us that they had been "...made aware of many providers that are considering themselves a pedorthist without that degree program and national certification.  They may have a credential, but not one that is as stringent as those certified by the ABC or BOC.  Thus, for the safety of our Medicare beneficiaries, we needed to rescind our initial CMS guidance regarding this group."  Who are these many providers that are considering themselves pedorthists without a degree or certification?  Where are they getting this credential?  What is the credential?  Pedorthists ARE ONLY certified by ABC and BOC, as are orthotists and prosthetists - all three have stringent educational requirements that lead to certification - all three are recognized as qualified suppliers in the medical policy for the Therapeutic Shoes for Diabetics benefit - but only pedorthists were singled out in CMS' decision to rescind the exemption.  And, of the three, pedorthists are the most uniquely trained/educated to supply the TSD.  CMS' confusion could not have come at a worse time for stand alone pedorthic facilities fighting a horrible economy and the prospect of additional expenses for surety bonds, and it created the perception that O & P was achieving the upper hand over pedorthists.

To further muddy the waters, additional communications from CMS indicated that they "...investigated the qualifications from your industry, and that did not include the ABC and BOC's credentialing programs. We conducted research on our own that was reflected on your industry websites and general educational background requirements. We are in agreement that the credentials for this industry are not consistent. You also stated that 51% of the pedorthic providers are in stand alone practices. As such, there is no physician or other licensed professional oversight for such operations. CMS does not wish to hold these practitioners at a higher standard, however, we are concerned over the quality of services that our Medicare beneficiaries may receive from individuals that have little or no qualifications but are able to furnish services to a vulnerable diabetic population."

If CMS investigated the qualifications from the industry, BUT DID NOT include the ABC and BOC credentialing programs, or, for that matter, CAPE or NCOPE standards for the schools, WHAT were they looking at?  There are only two organizations that establish the qualifications for pedorthists - again, along with orthotists and prosthetists - and that is ABC and BOC.

Also, the last time we checked, orthotists, prosthetists and pedorthists were not required to operate under the oversight of a physician or other licensed professional as they all operate by way of physician's (or other qualified prescriber's) prescription.

If CMS wanted to protect the beneficiary population from under- or non-qualified individuals, why are they singling out the one profession that - again - is uniquely trained/educated and certified to supply this population under the TSD?  Is creating an access issue whereby high-risk diabetics have to instead visit a practitioner who looks at the TSD as a secondary component to their practice, or an outright burden, providing the best possible care to an at-risk patient?  We think not.

All of this is not to say that CMS is not to blame for a lot of the misunderstanding.  Once again, after significant PFA input into the draft DMEPOS facility accreditation standards, CMS DID NOT define who qualified suppliers for the DMEPOS items listed in Appendix C are.  PFA has long advocated that qualified indivdiuals are "credentialed (ABC or BOC certified or state licensed) orthotists, prosthetists and pedorthists, and podiatrists."  CMS instead determines that "Individuals supplying the item(s) set out in this appendix must possess specialized education, training, and experience in fitting, and certification and/or licensing" to be qualified.  I think we would all agree that this doesn't clearly define who is truly qualified, but rather leaves a lot open to interpretation and enforcement confusion.  CMS failed to grasp that supplying, for example, custom made shoes and orthoses to a high risk diabetic patient with multiple complications requires more than learning how to "fit" and obtaining a certificate to that effect -a skill that can be achieved through the ABC Certified Fitter of Therapeutic Shoes or the BOC Footwear Specialist processes.  This, in comparison to recognizing an individual specifically trained and educated to a much greater extent - such as an ABC C. Ped. or BOC Pedorthist.  If CMS was concerned about non-qualified individuals applying as a Medicare DMEPOS supplier on the CMS-855S form, why didn't they take the approach that was used with CR 3959 in October 2005 which required that orthotists, prosthetists and pedorthists in states that licensed those professions, provide proof of licensure to ensure that they were qualified and could maintain their Medicare DMEPOS supplier status?  They could have certainly issued a Change Request requiring existing enrolled and newly enrolled/reenrolled/reactivated pedorthists to provide proof of credential or license in order to determine that they were indeed qualified, and remain on the list of exempted professionals.

We all know that the already-small pedorthic profession is contracting because of the significant pressures that are being placed on it.  It is a responsibility of all of the organizations representing this small but critically important component to the healthcare continuum to take a role in protecting it from unnecessary or illogical and usually costly burdens.

Could PFA's messaging to the membership have been handled differently?  Of course it could have.  However, as usual, PFA has taken a beating from the pedorthic community because they perceived the organizationas having not acted on their behalf when, in fact, we have been working at it for two months (and it wasn't just PFA that was in their sights - ABC and BOC have also been mentioned in numerous forums for not having stepped in on this issue).  The fact that CMS lacks attentive political leadership during this transitory period hindered our ability to fully utilize our allies in Congress to help push this.  Instead, we needed to develop a strategy to involve our members and the organizations that they are most professionally intimate with. Additionally, and again, we might disagree on this philosophy, but as their credentialing and accrediting organizations, there is a duty on your part to protect your certificants/accreditants from bad decisions made by government regulators, just as PFA has. With this in mind, PFA determined the strategy best to achieve its goal on behalf of its membership, and then executed the plan.  At the time, it was determined that it wasn't in PFA's best interest to reveal its plans beforehand. Honestly, PFA has to be realistic in understanding that, while we share common members/certificants/accreditants, each of the organizations have different stakes in the issue and for ABC and BOC, facility accreditation is a revenue generator and one of your reasons for being.  No one is faulting that, but it is important to recognize that that can be a factor in how you are able to respond to certain issues.

I hope that this clarifies PFAs actions on this issue. We will keep you updated as our efforts move forward.

Brian K. Lagana

Executive Director

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