How Will Medicare Prior Auth Work?

The DME industry has been abuzz ever since CMS announced a March 19, 2017 rollout date for prior authorization for general DMEPOS. Although the initial rollout is limited in scope, MiraVista projects that it will lay the foundation for a robust expansion in 2018. Prior authorization has the potential to make a huge impact on DME suppliers, but how exactly will prior authorization work?

The prior authorization process will require that DME suppliers obtain approval from Medicare before delivering product. The process will help ensure that all requirements are met before the item is provided to the beneficiary and before the claim is submitted for payment. CMS adopted the prior authorization process to help prevent questionable billing practices and improper payments for DMEPOS items.

Per the final rule posted in December 2015, the new prior authorization process for DME will not require any additional documentation…it will require the same documentation necessary to support Medicare payment today. Only, the documentation will have to be submitted earlier in the process.
It is worth noting that prior authorization is not an exemption from audits. Some required documents are collected after the prior authorization request has been processed (i.e. Proof of Delivery, documentation of continued use and continued medical need, etc.), and those documents are subject to further scrutiny via audits.

We think prior authorization for general DMEPOS will result in real, positive change for the DME industry as a whole. And it will soon be available to ALL suppliers. Want to know more? Join us January 31, 2017 for National Prior Authorization for DME: Seriously. Big. Deal. During this online forum, we’ll discuss the benefits and requirements of prior authorization and project what you can expect as the authorization program expands. Register today!