AOPA readies to monitor new prior auths

WASHINGTON - The American Orthotic & Prosthetic Association is “interested” to see how the new prior authorizations for certain L codes work out, says Joe McTernan.

CMS in February announced it was adding six lower limb prosthetic codes to the prior authorization list for DMEPOS.

“We are hoping to track the affirmation rates, both positive and negative, to see what the impact is on beneficiaries and how we can respond to that,” said McTernan, director of coding and reimbursement services, education and programming. “The PA process, as a concept, is not one that AOPA is necessarily against, but we have been and remain concerned that if it is not done effectively and fairly, that patients will, ultimately, be the ones who suffer through reduced access to medically necessary, high-quality clinical care.”

Phase one begins May 11 in California, Michigan, Pennsylvania and Texas—one state in each of the four DME MAC jurisdictions, before phase two rolls out nationwide on Oct. 8.

The selected codes (L5856, L5857, L5858, L5973, L5980 L5987) aren't surprising, as they typically have higher reimbursements and a higher burden of documentation for payment, say industry experts.

“These can go into the several thousands of dollars,” says Kelly Grahovac, general manager at The van Halem Group. “You don't want to put these out there, with the time involved and really working with the patient to make them, and then bill it and get denied for it not being covered.”

Overall, the industry views prior auths, which have been in effect for power mobility devices for several years and were extended to Group 2 support surfaces in 2019. However, with anything new, there are always concerns, says McTernan, who recently attended advisory council meetings for Jurisdictions B and C.

“They have not had a whole lot of direction from CMS on how this is going to work,” he said. “We're interested to see how it's going to work out.”