Proposed rule to expand use of Medicare prior authorizations for DMEPOS

As reported in an article from The Hill,CMS is proposing to expand the use of “prior authorizations” for power wheelchairs and scooters and to utilize the prior authorization process for other categories of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). The aim of the proposed rule is to reduce improper payments and fraud, particularly for high-priced DMEPOS items that are often aggressively marketed to both patients and doctors. CMS expects the expanded use of prior authorizations will save Medicare $100 million to $740 million over a ten-year period.

Under the current system, Medicare generally determines coverage for power wheelchairs and scooters after the item has already been delivered to the beneficiary. If Medicare ultimately denies coverage, the individual patient is responsible for the cost of the device. Under the proposed prior authorization process CMS Administrator Marilyn Tavenner indicated that “…Medicare beneficiaries will have greater confidence that their medical items and services are covered before services and supplies are rendered. This will improve access to services and quality of care.

Medicare adopted the use of prior authorization for certain power mobility devices as part of a demonstration program that covered seven states (California, Florida, Illinois, Michigan, New York, North Carolina, and Texas) in 2012. The proposed rule, published in the May 28, 2014 Federal Register, would expand the use of prior authorizations to 12 additional states, including Arizona, Georgia, Indiana, Kentucky, Louisiana, Maryland, Missouri, New Jersey, Ohio, Pennsylvania, Tennessee and Washington. The proposed expansion would also add additional DME items, supplies and prosthetics and orthotics to the list requiring prior authorization from Medicare. CMS is soliciting public comments on this prior authorization process and the criteria for establishing the list of items requiring prior authorization. The deadline to submit comments is July 28, 2014.

CMS explained that the prior authorization process would not result in a delay for the patient receiving the medical device. The proposed process would provide for a Medicare determination on initial requests for devices within 10 days and a response on all other requests within 20 days. CMS also proposed a two-day review period in cases where the life or health of the patient could be jeopardized under the standard 10- or 20-day review period.

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