Stakeholders say prior auths need to be timely, efficient

WASHINGTON - Although industry stakeholders are still combing through a plan to implement a prior authorization (PA) process for certain DME, they think it could be a good thing—with a few caveats.

PAs can provide assurance that the criteria for medical necessity have been met and that the claim will likely stand up under an audits. Both mean the provider is more likely to get paid.

“I think folks generally support it, but it's got to be done on a timely basis and it's got to be efficient,” said Cara Bachenheimer, senior vice president of government relations for Invacare.

In a proposed ruled published in the May 28 Federal Register, CMS seeks comments on such a prior authorization process, as well as the criteria to determine what DME is over-utilized and should be included in the process.

Right now, the agency has a “master list” of 134 codes that meet its criteria, mostly L-codes pertaining to lower limb prostheses. Also included: power mobility devices (see related story), negative pressure wound therapy (NPWT), pressure reducing support surfaces and CPAP devices.

“It's not a huge scope when you look at the list of items,” said Bachenheimer. “Should there be more? Less? We'll need to look at that and see if there are other items that need to be on there.”

One big question mark: turnaround time. The proposal states that Medicare or its contractor would make a “reasonable effort” to render a decision within 10 days of receiving the initial request, two days for an expedited request, and 20 days for a resubmission.

“There are some challenges when you look at a 10-day window,” said Kim Brummett, senior director of regulatory affairs for AAHomecare. “When patients are discharged from hospitals to home, even two days can cause a delay in discharge.”

Brummett is also concerned about applying a prior authorization process to NPWT and CPAP, both of which have ongoing documentation requirements.

“How long would the PA last?” she said. “Would you have to get it twice?”

Despite the unanswered questions, stakeholders are encouraged by the success of a demonstration project implemented in 2012 that requires prior authorizations for power mobility devices. Although there's no hard data yet on whether the demo has reduced audits, it has certainly streamlined the payment process, say stakeholders.

“When auditors request additional documentation to support the claim, they end up saying, 'OK, this has gone through the PA process,'” said Seth Johnson, vice president of government affairs for Pride Mobility. “That's pretty much the end of it.”

Comments on the proposed rule are due July 28.