CMS recently issued a final rule establishing a prior authorization process for certain durable medical equipment, prosthetics, orthotics and supplies. According to a press release from CMS, the rule was created to prevent “unnecessary utilization” of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) items and to improve consistency with Medicare coverage, coding and payment rules.
The prior authorization process under the final rule will not require new clinical documentation requirements; instead, it will require suppliers to provide information before the item is furnished to the beneficiary and before the claim is submitted for payment. The purpose of the change is to keep beneficiaries from being held responsible for payment of items that are not eligible for Medicare payment. An expedited process will be used in cases where delay can jeopardize the health of beneficiaries.
CMS previously addressed concerns about improper payments through the implementation of the DMEPOS Competitive Bidding Program as well as heightened screening of suppliers, according to the press release. In addition, CMS recently expanded its 3-year prior authorization demonstration for power mobility devices.
The final rule addresses DMEPOS items beyond power mobility devices. The rule creates a “Master List” of items meeting specific criteria that are potentially subject to prior authorization; a subset of items on the Master List designated the “Required Prior Authorization List”; and a prior authorization program for the items on the latter list.
The Master List includes 135 DMEPOS items CMS has identified as being frequently subject to unnecessary utilization. The list includes items on the DMEPOS Fee Schedule with an average purchase fee of $1,000 or greater or an average rental fee schedule of $100 or greater (adjusted annually for inflation) and that have been the subject of either HHS Office of the Inspector General (OIG) or U.S. Government Accountability Office (GAO) reports that are national in scope and published in since 2007, or DMEPOS Service Specific Reports of the Comprehensive Error Rate Testing Annual Medicare Fee-for-Service Improper Payment Report DME Report.
CMS will initially implement prior authorization for the Required Prior Authorization List, for which prior authorization will be required. This list will be published in the Federal Register 60 days’ notice prior to implementation of prior authorization for those items and will require all relevant documentation to be submitted for review prior to furnishing the DMEPOS item to the beneficiary and submitting the claim for processing. CMS or its contractors will review each prior authorization request and provide either a provisional affirmation or non-affirmation decision. If a claim receives provisional affirmation and meets all other requirements, it will be paid. If a claim receives a non-affirmation decision, it will be denied. Unlimited resubmission of prior authorization requests is allowed.
According to the press release, CMS or its review contractor will make a reasonable effort to determine initial prior authorization within 10 business days and resubmission prior authorization within 20 business days. An expedited review process will be available for situations in which the standard timeframe for prior authorization could seriously jeopardize the health of the beneficiary. The request for expedited review must provide rationale supporting the request.
The final rule is available to view at https://www.federalregister.gov/articles/2015/12/30/2015-32506/medicare-program-prior-authorization-process-for-certain-durable-medical-equipment-prosthetics.