CMS to require prior authorization for certain durable medical equipment

Starting next month, the Centers for Medicare & Medicaid Services (CMS) will begin requiring prior authorization for certain durable medical equipment, prosthetics, orthotics, and supplies.

The move, effective Feb. 29, follows several years of efforts by CMS to reduce fraud and overuse of these items, also known as DMEPOS.

Most recently, CMS implemented the DMEPOS Competitive Bidding Program and increased screening of suppliers, as authorized by the Affordable Care Act. In addition, CMS started a prior authorization demonstration program for power mobility devices, eventually expanding the trial from seven to 19 states.

The new process goes well beyond power mobility devices. It creates a “master list” of 135 DMEPOS items, a subset of which will be subject to prior authorization. CMS will publish this “required prior authorization list” 60 days before implementation.

If prior authorization is required for an item, the requester (usually the DMEPOS supplier) must provide CMS evidence that the item complies with all applicable Medicare coverage, coding, and payment rules. This must be done before the item is provided to the Medicare recipient or a claim is filed for processing. While the supplier will typically provide this information, prescribing or ordering physicians should not be surprised if the supplier asks their office for assistance.

After CMS receives the Medicare documentation, the agency or its review contractors will conduct a medical review and decide whether to provisionally affirm the request. Medicare will pay claims filed with a provisional affirmation if other requirements are met. Claims with a non-affirmation or no decision will be rejected, although the agency will allow unlimited resubmissions of prior authorization requests.

Medicare says it or its review contractors will try to process prior authorization requests within 10 business days and process resubmitted requests within 20 business days. Expedited review will be available in certain circumstances, such as instances where waiting the normal time frame for prior authorization could seriously endanger the life or health of the patient.

CMS will also communicate specific prior authorization guidance in the future.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians