GAO: Extend prior auth program

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Wednesday, May 23, 2018

WASHINGTON – CMS should continue with its prior authorization programs and expand prior authorizations to include power wheelchair accessories, according to a new report from the Government Accountability Office.

The prior authorization demonstration project launched in seven states in 2012 and was expanded to an additional 12 states in 2014. Originally set to expire Aug. 31, 2015, the deadline was pushed to Aug. 31, 2018 and CMS has not announced plans to extend the deadline again.

The GAO estimates the prior auth program for power mobility devices saved nearly $608 million though March 2017.

Although the HME industry is largely in favor of prior authorizations, suppliers reported some challenges, such as obtaining the necessary documentation from referring physicians.

In addition, suppliers expressed concerns about whether PMD accessories are subject to prior authorization. CMS in 2017 said if an accessory is essential to the functioning of a K0856 or K0861 wheelchair, it would be considered part of the base and covered under the prior authorization process. 

CMS neither agreed nor disagreed with the GAO’s recommendations but said it would continue to evaluate the prior auth program and take the GAO’s recommendations into consideration in developing plans or determining next steps, according to the GAO.