Approved PAR? Proceed with caution, consultants say

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Friday, September 6, 2019

YARMOUTH, Maine – Industry consultants warn a recent uptick in the number of approved prior authorization requests (PARs) isn’t always a good thing.

Consultant Martin Szmal has noticed clients receiving an increasing number of wrongly approved PARs, putting their clients at risk in potential audits.

“If a provider provides equipment on an affirmative PAR and it’s later audited and determined the decision was made on incorrect information, that provider would still be held liable for payment back to Medicare,” said Szmal, president of the Mobility Consultants.

CMS has ramped up the prior authorization program considerably in the past year. In 2018, it expanded a demonstration project requiring PARs for standard power mobility devices from 19 to all states.

Then in July, the agency began requiring providers to submit PARs for seven codes for complex rehab power mobility devices.

“I’m all for affirmative PARs, but I’m not for (rubberstamping) them, just trying to get paperwork off their desks and moving on to the next one,” Szmal said.

Consultant Claudia Amortegui has also noticed “some” wrongly approved PARs and she thinks it comes down to one key difference between the PAR process and the former ADMC process. While the ADMC process covered bases and accessories, the PAR process covers only bases, so it’s less comprehensive.

“It’s not line-by-line like the ADMC was,” said Amortegui, president of the Orion Group. “So the concern is with the parts and pieces. You’re pretty much protected if they hit you on the base, but it’s everything else.”

Consultant Sylvia Toscano has been advising clients who believe they’ve wrongly received affirmative PARs to obtain ABNs, especially if they were looking for a denial so they can then submit to a secondary insurer.

“You need to add the GA modifier to the claim, instead of a KX modifier, to obtain a PR (patient responsibility) denial,” said Toscano, president of Professional Medical Administrators. “That’s a billing tactic that they could technically use.”

Unfortunately, however, a number of providers are taking the approved PARs and “running with them,” Toscano said.