Prior authorizations will ease pressure, CMS says

WASHINGTON - CMS answered a few key questions about the PMD demonstration project during a Special Open Door Forum last week. Among the most important: Will the required prior authorizations help protect providers against post-payment reviews?

CMS officials said they should, at least with MAC and RAC audits on medical necessity and other elements included in the prior authorizations.

But "there could be other requirements that are not reviewed during the prior authorization process, like the home assessment," said Melanie Combs-Dyer, deputy director of the Provider Compliance Group at CMS.

Also, providers may still be subject to CERT audits and fraud-fighting audits like ZPICs, CMS officials said.

Still, the audits that do take place should be easier on providers, Dyer said.

"Hopefully that would be a much shorter review--you've got that on file and it's nothing you'd have to write to the physician and track down," she said. "We really do believe that having in place this prior authorization process will make life easier for suppliers in terms of post-payment reviews."

Last week's forum was the first opportunity that providers had to get more information about the revamped seven-state PMD demo since CMS announced Feb. 3 that it would drop the prepay review phase. The demo is set to begin on or after June 1.

Other new information: Prior authorization decisions will be sent to providers, physicians and patients within 10 business days. If denied, the decisions will come back with detailed explanations. The number of allowed resubmissions is unlimited, with 30-day response times from the DME MAC.

Several aspects of the process will remain the same: The agency will still allow a 48-hour expedited review of prior authorizations for emergency cases; providers who do not want to go through prior authorizations may choose not to, but will take a 25% reimbursement cut (after a three-month grace period); and physicians will still be able to bill for time spent preparing prior authorizations (providers may submit that paperwork on the physician's behalf, without the extra compensation).

CMS will continue to offer educational outreach in the coming months, including monthly Open Door Forums through July.