The National Association for the Advancement of Orthotics and Prosthetics announced their efforts to draft a comprehensive response to the proposed rule released by CMS for prior authorization for certain Durable medical Equipment, Prosthetics, Orthotics and Supplies.
“When you compare the [Recovery Audit Contractor] audits and the financial stresses that have occurred over the past several years in the orthotic and prosthetic field, it is hard not to be enamored with the idea that you could get approval upfront before providing the care and before expending those resources to purchase components that go into that ultimate device only to have them recoup later down the road,” Peter W. Thomas, JD, general counsel of the NAAOP, stated in NAAOP webcast. “We want to make sure that our members and the O&P field really understand what prior authorization is when CMS proposes it and how it compares to private payer prior authorization, and we want to make sure that we promote those changes to the proposed rule that would make prior authorization workable.”
Under the proposed rule, practitioners would obtain a “provisional affirmation” prior authorization from CMS before providing certain lower limb prostheses to patients and then billing the Medicare program. If CMS denies the prior authorization request, then practitioners may resubmit prior authorization requests multiple times. However, if a supplier submits a final claim without prior authorization, the claim will be denied and the decision will have to be appealed through an administrative law judge.
According to the news release, the NAAOP is working on getting major safeguards included into the final ruling. These include an obligation from CMS to pay the claim after approval of the prior authorization request and barring CMS from reopening the claim after the care has been provided to question whether the documentation supports medical necessity. NAAOP believes a demonstration project or pilot program should be put into place to ensure that prior authorization on certain lower limb prostheses does not compromise patient care. CMS should also list specific types of documentation it expects in the prior authorization request in the final ruling.
The NAAOP encourages its members to submit comments to CMS on the proposed rule. All comment letters are due by July 28.