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Alternatives to State Licensure
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State Licensure is the accepted benchmark for improving consumer protection through establishment of minimum standards of education and experience required of practitioners providing O&P patient care. However, you may live in a state that has a sparse population and therefore a relatively small number of practitioners. This can make it more difficult to provide the effort needed to establish and maintain O&P licensure. In states that are unwilling or unable to support the establishment of a legislative mandate for licensure; can other measures be taken? A few states have achieved alternatives to licensure, through a variety of methods. This Licensure Corner will examine the details of regulations, short of full licensure, that have been enacted in some states. This information could provide a basis for action that may bring some degree of regulation to your state without the cost and oversight created by licensure.

Mississippi established a certification requirement in 1972. This regulation was revised in 2011 and states, “No person shall practice orthotics or prosthetics in the state unless he or she is certified as an orthotist, prosthetist, or both.” The Mississippi Code also contains guidance on supervision rules and provides for monetary and civil penalties for violation of the regulation. While it is unclear what governmental body enforces the Mississippi Code, the framework is in place to assure that only those individuals who possess education and training, demonstrated through certification, are qualified to provide O&P patient care.

Another example of a state with a regulatory requirement that does not include issuing a formal license is North Dakota. The state has a regulation that reads, “A person may not sell or deliver durable medical equipment directly to a consumer unless licensed by the board as a retail durable medical equipment retailer.” The regulation contains a certification requirement for provision of custom orthotics and prosthetics. In North Dakota, the board of pharmacy is the governing authority to enforce this requirement.

In 2008, Nevada adopted the state board of pharmacy regulation LCB File No. R033-07, which licenses facilities to provide O&P care and must indicates they must be staffed by ABC- and/or BOC-certified practitioners. The regulation is quite detailed in the oversight of the facility but not to the individual practitioner except regarding current certification and compliance with code of ethics and scope of practice.

In 2011, the Louisiana Association of Orthotists and Prosthetist (LAOP) worked to achieve a rule within the Louisiana Medicaid enrollment process requiring that, “DME suppliers enrolling as a company with Certified Orthotist, Certified Prosthetist, or both must be accredited by one of the following two boards: American Board for Certification in Orthotics, Prosthetics & Pedorthics, Inc., Board for Orthotist/Prosthetist Certification.” This established that facilities providing comprehensive orthotic and prosthetic care are required to be accredited in order to participate in the state medical assistance program. Enforcement was accomplished through exclusion from reimbursement from the program. In addition to the full array of patient care, administrative, quality, safety, and compliance standards required of the accreditation programs, there is also a practitioner certification requirement. The result is to require certified practitioner level of expertise functioning in the facility that undergoes the accreditation survey process at least every three years. Although the facility accreditation requirement has not been implemented through nationwide CMS policy, it has been sought for several years. Individual states can work to achieve this level of imposing minimum standards, short of achieving full licensure of O&P professionals.

Some large private healthcare insurers require O&P facility accreditation by a deemed accreditation organization as a condition for participation in their network. This requirement affords their subscribers a measure of quality assurance by accredited O&P care providers. In many of those situations, O&P practitioners met with insurance groups in their areas with whom they contract to encourage the inclusion of accreditation as a provider clause in their agreements. This presents an opportunity to establish of some measure of minimum provider standards in lieu of licensure.

There are pros and cons to the ways these states have established standards for the provision of O&P care. One shortcoming of the examples discussed above is that they lack enforceable provisions to address consumer complaints. Presumably, this is left up to the credentialing organizations whose practitioners would be subject to sanctions if substantiated grievances are filed against their credential holders. While implementing an alternative mandatory certification or accreditation requirement is a less costly method of creating a baseline criterion, the ability to enforce the regulation may be less effective.

Establishing formal licensure for the orthotic and prosthetic profession brings recognition as allied health professionals. States that have established a minimum requirement of practitioner certification or facility accreditation have taken a first step toward protecting O&P consumers; many states remain with neither licensure nor minimum expertise required to provide O&P care.

The Licensure Corner has always invited and welcomed comment, questions, or topic suggestions. There may be some measures that have been implemented or are being pursued in your state that have not been covered in this edition. The members of the Academy Licensure Committee, who worked collaboratively to write this column, would like to update your fellow Academy members and include your state in these discussions. Please contact the Licensure Corner at licensure@oandp.org and let us know the status of progress toward O&P licensure (or alternatives) in your state. 

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