Prior auth legislation could nudge CMS forward

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Friday, May 19, 2017

WASHINGTON – AAHomecare hopes a new bill will be the legislative push for CMS to speed up a prior authorization process for certain HME.

Rep. Marsha Blackburn, R-Tenn., introduced H.R. 2445, the DMEPOS Access and Transparency Act of 2017 or DATA Act, on May 17. The bill follows a prior authorization process being in place for power mobility devices since 2012, and a process being in place for two complex power wheelchair codes since March of this year.

“I think having legislation will make it easier for CMS to embrace and move forward with doing some of those prior authorization processes that aren’t as similar to how the process for PMDs works,” said Kim Brummett, vice president of regulatory affairs for AAHomecare. “I know CMS feels logistically hand-tied by what they feel they have the authority to do.”

Back in 2015, CMS issued a final rule that would establish a prior authorization process for certain high-priced HME, saying it would work off of a “master list” of 135 codes. But it wasn’t until 2017 that the agency picked the ball back up and selected two codes from that list—the two complex power wheelchair codes—for prior authorization.

With prior authorization seen as a key way to help rein in excessive audits, that’s not fast enough, AAHomecare says. Additionally, Blackburn’s bill would also exempt claims that have been approved through the prior authorization process from pre- and post-payment audits.

“We’re still going to have reviews where they are looking for proof of delivery or required documentation,” said Brummett. “But the medical necessity piece of the audits has always been the most subjective, so taking that away is huge.”

Blackburn’s bill is similar to a previous version introduced in 2015, but it adds a provision requiring a more detailed prior authorization process for respiratory equipment. Per the provision, the Department of Health and Human Services would establish a standard for medical necessity evaluation requests for physicians, hospital referral agents and non-physician practitioners.

“The respiratory folks were very clear that they want it to be prescriber-driven so that the supplier isn’t always caught in the middle,” said Brummett.