Starting today, the second phase of Medicare’s prior authorization program requires suppliers in 12 new states to obtain prior approval for select off-the-shelf braces before delivering products to beneficiaries. The requirement applies to:
Medicare rolled out the initial phase in April for suppliers in California, Florida, Illinois, and New York. Today’s phase-two implementation includes:
The program launches in all remaining states on October 10, 2022.
Types of Medicare Authorizations
Many suppliers approve of prior authorization as a reasonable way to reduce costs associated with denials and recoupments, so long as the process is efficient. The current program offers routine authorization responses in five business days, but two-day expedited responses are available upon request. With the approved prior authorization in hand, suppliers can release claims with confidence that Medicare will not deny or recoup related claims due to insufficient medical record documentation, invalid standard written orders, or issues with same and similar equipment.
Suppliers can bypass the prior authorization requirement in cases where any delay in the provision of equipment poses an immediate risk to the health of the patient, but suppliers assume all risk for the adequacy of coverage documentation. In emergency cases, suppliers should bill with the ST modifier to alert Medicare there is no corresponding authorization. Doing so will suspend claims for prepayment review of medical records, and payment may be delayed up to 45 days.
We advise suppliers to work closely with referral sources. Early conversations in the ordering process provide the best opportunity to review and discuss the level of detail in the supporting chart notes. The ultimate goal is to screen the records and ensure they make a compelling case for payment.
SOURCE LINKS
https://cgsmedicare.com/jc/pubs/news/2022/03/cope25544.html
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/DMEPOS/Downloads/Operational-Guide-for-DMEPOS-PA-current.pdf
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/DMEPOS/Downloads/DMEPOS-PA-Frequently-Asked-Questions-06-01-2018.pdf
- Back braces billed with procedure codes L0648 and L0650, and
- Knee braces billed with procedure codes L1832, L1833, and L1851.
Medicare rolled out the initial phase in April for suppliers in California, Florida, Illinois, and New York. Today’s phase-two implementation includes:
- Arizona
- Georgia
- Kentucky
- Maryland
- Michigan
- Missouri
- New Jersey
- North Carolina
- Ohio
- Pennsylvania
- Texas
- Washington
The program launches in all remaining states on October 10, 2022.
Types of Medicare Authorizations
Many suppliers approve of prior authorization as a reasonable way to reduce costs associated with denials and recoupments, so long as the process is efficient. The current program offers routine authorization responses in five business days, but two-day expedited responses are available upon request. With the approved prior authorization in hand, suppliers can release claims with confidence that Medicare will not deny or recoup related claims due to insufficient medical record documentation, invalid standard written orders, or issues with same and similar equipment.
Suppliers can bypass the prior authorization requirement in cases where any delay in the provision of equipment poses an immediate risk to the health of the patient, but suppliers assume all risk for the adequacy of coverage documentation. In emergency cases, suppliers should bill with the ST modifier to alert Medicare there is no corresponding authorization. Doing so will suspend claims for prepayment review of medical records, and payment may be delayed up to 45 days.
We advise suppliers to work closely with referral sources. Early conversations in the ordering process provide the best opportunity to review and discuss the level of detail in the supporting chart notes. The ultimate goal is to screen the records and ensure they make a compelling case for payment.
SOURCE LINKS
https://cgsmedicare.com/jc/pubs/news/2022/03/cope25544.html
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/DMEPOS/Downloads/Operational-Guide-for-DMEPOS-PA-current.pdf
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/DMEPOS/Downloads/DMEPOS-PA-Frequently-Asked-Questions-06-01-2018.pdf
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