Members in the News
Michelle Stein, Inside Health Policy, 6/16/2014
inside news on federal health and safety regulation
May 29, 2014
DME Suppliers, Ambulances: Prior Authorization Could Be A
medical equipment suppliers and ambulance providers say CMS’ recently announced
prior authorization programs
could be a step in the right direction for fighting fraud while preserving
access, although they have some concerns
about the DME prior authorization timelines.
If prior authorization for some DME is handled correctly, it
could solve a lot of issues in the sector, according to American
Association for Homecare Vice President for Regulatory Affairs Kim Brummett.
Brummett said she hopes that CMS will work with the industry on the proposed
DME prior authorization process as the agency did on the power mobility device
CMS late last week announced it would expand the power
wheelchair prior authorization demonstration, which was launched
in 2012, to 12 more states. Despite initial industry concerns, both CMS and
some DME suppliers have characterized the demonstration as a success, and the
agency said it plans to build off the success by testing prior authorization for
scheduled ambulance transport and hyperbaric oxygen therapy. It also proposed a
prior authorization process for certain DME, and the agency says the proposed
rule is estimated to reduce Medicare spending by $100 million to $740 million
over the next 10 years.
Brummett said that expanding the
power mobility device demonstration is something that we’ve wanted for a
long while. It sets the right balance making sure that devices are
covered and fraud prevention, she said.
Morton, executive vice president at the National Association for the Support of
Long Term Care, said that while the group plans to keep a close eye on the proposed
prior authorization for some DME and how it would practically work, from an
appeals standpoint prior authorization could be beneficial and a step in the
right direction. The agency has proposed that unlimited resubmissions be
allowed if prior authorization is denied, but a decision cannot be appealed,
the proposed rule says.
Brummett said AAHomecare is still reviewing the rule, but
she hopes that CMS will work with the industry on the proposed
DME prior authorization process as it did on the power mobility device
demonstration. The proposed rule seeks feedback on setting the DME prior
authorization process and creating the “Master List” of items that could be
subject to prior authorization.
CMS says decisions on initial requests would be postmarked within
10 business days and subsequent requests would be
processed within 20 business days. CMS also has proposed an expedited review
Brummett said the timeframe for
prior authorization should depend on the type of DME. Most DME is ordered
after a hospital discharge or when there is an immediate need, and the
beneficiaries don’t have days to wait for prior authorization, she said. Most
private payers pre-approve DME within hours, and for some DME, CMS will need to
be that fast as well, she said. Morton also said that there will be concerns if
the way the DME prior authorization process is done slows patient access to the
DME. When the government intends to do something quickly but it doesn’t happen
that way, it can be hard to change an established process, she said. Morton
pointed to issues with the therapy manual medical review process, which was
also supposed to have a 10-day review time. NASL released a survey in December
that showed at least 33percent of MMR claims submitted by members since the
beginning 2013 were still waiting to be processed. The hope is that delays won’t
accumulate with this program, Morton said.
Brummett also said that there should be a way to measure the
prior approval process and ensure consistency across the
process. Language should also be included in the rule to say that if prior
authorization is approved, then no post-pay review for medical necessity should
be conducted, she added.
Tristan North, senior vice
president of government affairs at the American Ambulance Association, said the group is supportive of the prior
authorization policy laid out by CMS. The
group had previously discussed with CMS using prior authorization for
addressing dialysis transportation fraud, North said, as the group has seen
Congress try to address the issue by cutting reimbursement for ambulance
transport in previous physician payment patches. Cuts are not enough of a
disincentive for fraudulent providers who are still making money, but they hurt
legitimate providers, North said. This policy is viable if it is implemented
properly and there are safeguards on turn around time so that prior
authorization is approved in a timely manner, North added.
CMS says a prior authorization decision could affirm a
specific number of trips, and CMS may approve up to 40 round
trips per prior authorization request in a 60-day period.
The prior authorization demonstration for scheduled
ambulance transports will affect New Jersey, Pennsylvania and South
Carolina, and North noted that CMS had previously instituted a moratorium on
ambulance providers in the Philadelphia area. That helps keep bad actors out of
the program, but layering prior authorization on top of the moratorium is a good
option stop those still in the system, North said. — Michelle M. Stein (firstname.lastname@example.org
Copyright 2014 Inside
Washington Publishers. Reprinted with permission.