‘Pressure’ is on to expand prior auths

Friday, August 7, 2015

YARMOUTH, Maine – CMS recently extended a demo requiring prior authorizations for certain power mobility devices, and providers say it may be time to consider other product categories, too.

“I think prior auths could work for a lot of DME,” said Eric Hagan, director of business development for Green Bay, Wis.-based HME Home Medical.

CMS issued a proposed rule in May 2014 seeking comments on prior authorizations for other DME.

The agency has since indicated, however, that a final rule is unlikely before 2017, say stakeholders.

“There’s a lot of pressure for them to expand the final rule because everybody likes it,” said Kim Brummett, senior director of regulatory affairs for AAHomecare. “But their approach was unworkable and I think our comments gave them quite a bit of pause.”

Pressure is on legislatively, as well. In May, Rep. Marsha Blackburn, R-Tenn., introduced a bill that would require prior authorizations for certain high-cost DME, including oxygen.

Providers say other product categories that could benefit from prior authorizations are hospital beds, manual wheelchairs and low air loss mattresses. The reason? They are all heavily audited, they say. 

“I’d like to replace audits with prior approvals done properly,” said Frank Trammell, president and CEO of Matthews, N.C.-based Carolinas Home Medical Equipment. “But they have to be fast.”

Fast is key so that patients waiting to be discharged from a hospital don’t get delayed by an unwieldy process, say providers. CMS should take note of how private insurers issue prior auths, in many cases in an hour or two, they say.

“It would be nice, but I just don’t see them moving fast enough,” said Dan Heckman, president and general manager of Heckman Healthcare in Decatur, Ill. “You don’t want to slow down the process for beds and oxygen for pending discharges from an acute care setting.”