CMS publishes prior auth rule

Tuesday, December 29, 2015

BALTIMORE – CMS today issued a final rule that would establish a prior authorization process for certain durable medical equipment.

The agency, which issued a proposed rule in May 2014, had originally said a final rule would not be forthcoming until 2017.

CMS says prior authorizations will reduce overutilization of certain high cost DME without impeding beneficiary access. The agency has a “master list” of 135 codes that meet that criteria and will be potentially subject to prior authorizations.

Specifically, that means items with an average purchase fee of $1,000 or greater, or an average rental fee of $100 or greater, (adjusted annually for inflation) and are the subject of:

• HHS Office of the Inspector General (OIG) or U.S. Government Accountability Office (GAO) reports that are national in scope and published since 2007, or

• Comprehensive Error Rate Testing Annual Medicare Fee-for-Service Improper Payment Report Durable Medical Equipment (DME and/or) Report’s DMEPOS Service Specific Reports.

CMS will publish the Required Prior Authorization List in the Federal Register with a 60-day notice before implementing prior authorization for those items.

The industry is generally in favor of prior authorizations, as long as they are done correctly. A chief concern is that approvals are done quickly.

In its announcement, CMS says either the agency or the review contractor will “make a reasonable effort to render an initial prior authorization determination within 10 business days and will make a reasonable effort to render a resubmission prior authorization determination within 20 business days. “ 

In May 2015, Rep. Marsha Blackburn, R-Tenn., introduced a bill that would require prior auths for certain high-cost DME, including oxygen. In September 2015, CMS extended a demo for power mobility devices. The demo kicked off in seven states in 2012.