CMS Updates DME Prior Authorization Process

DME prior authorization
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Before certain designated DMEPOS can be accepted for Medicare reimbursement, CMS has established an HME/DME prior authorization process. A Master List will be used to identify items that require DME prior authorization. There will be no additional documentation requirements. According to CMS, DME PA will help verify that applicable coverage, payment, and coding standards are followed before equipment or supplies are issued.

CMS depends heavily on a DME prior authorization comprehensive platform in which monthly expenditures decreased over a three-year period. From $12 million to $3 million in the program’s original seven states and from $10 million to $2 million in the program’s 12 additional development states that allow prior authorization in the new regulation.

Longstanding concerns for improper payments

CMS has long been concerned about fraudulent payments relating to these commodities, according to the organization. To reduce the burden on providers and suppliers, CMS will initially implement DME prior authorization for a subset of the 135 items on a master supply list. According to the final rule, the DME prior authorization process will require the same information that is already required to justify Medicare payment. It will simply be completed earlier in the process.

Reasons behind inadequate documentation

According to the Federal Register, 92% of the DMEPOS incorrect payment is related to insufficient documentation for the 2014 reporting period. Inadequate documentation is frequently the result of a simple error in the process of documenting the requirement for the equipment or supply:

  • A doctor forgets to include a date
  • A therapist fails to fill out a form

When it comes to the execution of the DME PA program, beneficiary advocates are concerned about CMS’s distortion of the facts.

Beneficiaries Should Know

  • Which products will require prior authorization. Items that require DME PA will be included in a subset of the Master List. Other things on the list “may” require DME prior authorization.
  • It is critical to have adequate documentation. Legitimate DME PA requests will result in the acquisition of equipment and supplies only if the paperwork is error-free, legible, and complete. Whenever feasible, have more people examine the DME prior authorization before submitting it.
  • Keep an eye on the rules of DME PA timeframes. Initial reviews take 10 business days, and re-submissions take 20 business days. There are no appeal rights, but there are unlimited re-submissions.
  • Understand that there is a procedure for submitting an expedited request for prior permission. Documentation indicating how the beneficiary’s life or health may be compromised, if the request is not expedited, must be supplied with the request. It remains to be seen how CMS will interpret “seriously jeopardized.”

Keynote:

Through sub-regulatory notifications, CMS intends to give specific DME PA advice. The Center for Medicare Advocacy will keep an eye on these communications as well as the execution of the DME Prior Authorization program.

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