HMEs beat back new prior authorization process

CHARLESTON, W.Va. - HMEs in West Virginia eagerly await the arrival of a revised provider manual that they expect to include a less "draconian" prior authorization process. Medicaid released a manual in mid-March that included a process that allowed only a doctor or a doctor's agent to submit a request. Previously, doctors handled the clinical and diagnostic components of a request, while providers handled the product-specific components. "We understand they're trying to establish more control and accountability on the part of physicians and keep utilization in check for HMEs, but do they need to put physicians in charge of the whole thing?" asked Pam Kaehler, president of the West Virginia Medical Equipment Suppliers Association. "We do the in-home assessments; we know the products." The new prior authorization process went into effect March 15. Soon after the manual's implementation date, however, the state association worked with doctors and referral sources to communicate to Medicaid the "issues, complaints and unintended consequences" of the new process, Kaehler said. "No one knew what we could and couldn't do," said Kaehler, executive director of Mon HealthCare in Morgantown, W.Va. In an unusual turn of events, Medicaid responded in late April by allowing Kaehler to read a draft of the revised provider manual, which included a "substantially improved" prior authorization process. The provider manual released in mid-March also added nebulizer compressors and portable oxygen to the list of HME requiring prior authorizations. Kelley Matusic, owner of My Family Medical in Hurricane, W.Va., said the recent changes haven't thrown a wrench in her operations, only because the company submits prior authorization requests for "every product that goes out the door." What does irk Matusic is that the state "requires prior authorizations, but prior authorizations aren't a guarantee of payment."