The Centers for Medicare & Medicaid Services (CMS) published a final rule regarding the reporting and return of overpayments identified by the supplier. The overarching premise of this rule is to clarify what is expected of suppliers and to codify just how far back these overpayments must reach. The regulation does not stipulate any NEW penalties for providers that do not comply, but there are plenty of existing regulations that assess fees and penalties for erroneous billing. When a provider has knowledge of these acts and omissions, penalties can be exacerbated. The major provisions are summarized below:
As Medicare looks to expand their prior authorization program into general DME, now is a good time to build efficiency into your existing prior authorization processes. Below we have outlined four ways to reduce authorization complexities.
The biggest cause of AR bloat (attributable to authorization procedures) stems from expired authorizations. Often times, authorizations are initially entered with only the minimal details necessary to setup (effective date, HCPCS and auth number). But to eliminate future headaches, we have to consider the end game and think through the eventual expiration and how many times the auth can be used. How will you know when a re-authorization is necessary? How will you know when the item should be converted to a purchase after reaching a cap? Most often, suppliers are not prompted to make these changes until we receive a denial.
To resolve this problem, we recommend establishing an “outtake” protocol where a team proactively scours your system for expiring Prior Authorizations to aggressively pursue re-authorization and cap conversions. For this to work, expiration dates must be entered initially when the authorization is set up. Then you can leverage reports in your billing system to identify expiring authorization and proactively pursue renewals and conversions.