CMS eyes expansion of prior auths

Friday, May 23, 2014

BALTIMORE – CMS may implement prior authorizations for certain durable equipment, it announced May 22.

Through a proposed rule to be published in the May 28 Federal Register, the agency will seek comments on the prior authorization process, as well as criteria for establishing a list of DME that is frequently overutilized. The agency has a “master list” of 134 codes that meet the criteria and that could be subject to prior authorization. It includes lower limb prostheses, negative pressure wound therapy, pressure reducing support surfaces and CPAP.

The proposed rule is projected to reduce Medicare spending by $100 million to $740 million over the next 10 years.

“With prior authorization, Medicare beneficiaries will have greater confidence that their medical items and services are covered before services and supplies are rendered,” stated CMS Administrator Marilyn Tavenner in a release. “This will improve access to services and quality of care.”

CMS also announced that it will expand its demonstration project for power mobility devices to 12 additional states: Pennsylvania, Ohio, Louisiana, Missouri, Maryland, New Jersey, Indiana, Kentucky, Georgia, Tennessee, Washington and Arizona, bringing the total number of states to 19.

The PMD demo has reduced spending from $11 million in September 2010 to $5 million in June 2013.

PMD stakeholders are largely supportive of prior authorizations. At the request of the Senate Finance Committee, the industry has drafted language that would expand the demo to all 50 states and would expand it to include all power mobility devices, including Group 3 wheelchairs.