CMS breaks silence on prior auths

Friday, May 6, 2016

WASHINGTON – CMS announced last week that two Group 3 power wheelchair codes—K0856 and K0861—will be considered for prior authorization.

In December, CMS issued a final rule that detailed its plans to establish a prior authorization process for certain DME in an effort to reduce unnecessary utilization and aberrant billing.

“This is literally the first piece of information that CMS has put out since the final rule about the next step,” said Cara Bachenheimer,senior vice president of government relations for Invacare. “The final rule didn’t give any indication about the process or how quickly it would be rolled out."

Until now, CMS has only referred to a “master list” of 135 products for which a prior authorization could be required, including CPAP devices and oxygen concentrators.

Mobility providers aren’t strangers to the process: A demonstration project requiring prior auths for a large number of power mobility devices has been going on in seven states since 2012, with 12 states added in 2014.

Provided that CMS implements the new prior authorizations the same way it has for the PMD demo, stakeholders say it will be a win for payers, providers, and beneficiaries.

“We just want to make sure that whatever the process is—in terms of the paperwork required, and the time it takes the payer to review the information, ask for additional information or approve it—it happens within a reasonable timeframe,” said Don Clayback, executive director of NCART. “The good news is, when it comes to the PMD demonstration, Medicare has a system in place that’s supported by everyone.”

The only standing criticism of the demo by stakeholders: Accessories aren’t included. Though CMS says that was an oversight, stakeholders want to make sure history doesn’t repeat itself.

“Group 3 chairs are typically provided with several accessories, which could be fairly expensive,” said Bachenheimer. “The announcement didn’t answer that question, but it’s important as CMS moves forward with prior authorization for these two codes.”