Rep. Blackburn introduces prior auth legislation

Stakeholders applaud the move, believe CMS isn’t moving fast enough to require PA for broader spectrum of HME
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Wednesday, May 17, 2017

WASHINGTON – Rep. Marsha Blackburn, R-Tenn., has introduced legislation that would require prior authorization for certain high priced HME, AAHomecare reported this morning.

H.R. 2445, the DMEPOS Access and Transparency Act of 2017 or DATA Act, would also exempt claims that have been approved through the prior authorization process from pre- and post-payment audits.

“This legislation will help stem the tide of Medicare audits that delay payments for providers and also tie up significant resources as providers answer and appeal them,” said Tom Ryan, president and CEO of AAHomecare. “We applaud Congresswoman Blackburn’s longstanding efforts to help rein in excessive audits by establishing an effective prior authorization process that will both improve cash flow for providers and also allow them to concentrate more of their resources and energy on serving their patients.”

H.R. 2445 builds on a previous bill introduced by Blackburn in 2015. The new bill adds a provision that outlines a more detailed prior authorization process for respiratory equipment. Per the provision, the Department of Health and Human Services would establish a standard for medical necessity evaluation requests for physicians, hospital referral agents and non-physician practitioners.

CMS launched the first phase of a prior authorization process for two complex power wheelchair codes, K0856 and K0861, in March. In this first phase, CMS has begun requiring prior authorizations in one state in each of the four DME MAC jurisdictions. In phase two, it will expand the program to the remaining states.

CMS pulled the two codes from a “master list” of 135 codes for which it says it may, eventually, apply the process*. The list also includes CPAP devices, semi-electric hospital beds, manual wheelchairs and oxygen concentrators.

As part of separate demonstration project, CMS has had a prior authorization process in place for power mobility devices since 2012. The process kicked off in seven states that year and expanded to an additional 12 states in 2014.