A proposed rule was published on May 28th, 2014, seeking comment on a prior authorization program for certain DMEPOS items. In the proposal, CMS collected a Master List of 139 HCPCS that have been determined to have frequent, unnecessary utilization. The list includes a variety of products such as hospital beds, RADs, Power Wheelchairs, Manual Wheelchairs, CPAPs, Support Surfaces and Lower Limb Prostheses. The proposal suggests that a certain portion of the HCPCS within the Master List would be carved out and that list (referred to in the proposal as the Required Prior Authorization List) would contain those HCPCS subject to the Prior Authorization requirement. Not all items within the Master List would be rolled out at once; instead CMS seeks to slowly infuse those HCPCS to the master list over time.
Once the final list of HCPCS subject to the rule is determined, the list would be released with a 60 day notice for providers to get prepared for implementation. If the proposal is finalized, the program would be rolled out on both a national and local level depending on the scale of unnecessary utilization uncovered during data analysis of each area. Also within the notice is a provision for CMS to use its discretion, at any time, to pause or suspend the program without creating a separate rule.
Once the final list of HCPCS subject to the rule is determined, the list would be released with a 60 day notice for providers to get prepared for implementation. If the proposal is finalized, the program would be rolled out on both a national and local level depending on the scale of unnecessary utilization uncovered during data analysis of each area. Also within the notice is a provision for CMS to use its discretion, at any time, to pause or suspend the program without creating a separate rule.
Should the rule become final, suppliers would be required to submit a request for Prior Authorization when billing for any of the selected HCPCS. The request would need to be submitted to the DME MAC and would have to include documentation to support that the item complies with all coverage, coding and payment rules. The DME MAC would then have 10 days from receipt of all applicable information to render its decision. In the instances where an expedited decision is necessary to preserve the life or health of the beneficiary, the proposal has included a provision for the DME MAC to render a decision within two business days of the receipt of all required documentation. Any claim submitted for one of the affected HCPCS without a valid prior authorization number would automatically be denied.
An interesting section of the proposal speaks to the applicability of this proposal to Competitive Bidding Areas: “We note that this proposal would apply in competitive bidding areas because CMS conditions of payment apply under the Medicare DMEPOS Competitive Bidding Program.” This means that contracted suppliers would not be exempt from this protocol should the final rule come into action.
The proposal goes on to indicate that because of the existing PMD Demonstration Program, PMDs would be excluded from the initial rulemaking – but this could be revisited once the original Demonstration has ended. The current PMD Prior Authorization Demonstration is active in seven states and not slated to expire until August 31, 2015. A proposal to expand that program into 12 additional states is already in the works as of April 4, 2014. The comment period for that proposal closed on April 18, 2014, with all comments in favor of an expansion.
For PARs that are denied or non-affirmed, the supplier would not be limited (based on this proposal) by a specific number of times that a request can be submitted for re-examination. The DME MAC would have 20 days to review the resubmission before rendering a decision.
The comment period for this proposal is open until 5pm Eastern Time on July 28, 2014. Suppliers that wish to submit comment can do so using this link: http://www.regulations.gov/#!submitComment;D=CMS-2014-0070-0001
An interesting section of the proposal speaks to the applicability of this proposal to Competitive Bidding Areas: “We note that this proposal would apply in competitive bidding areas because CMS conditions of payment apply under the Medicare DMEPOS Competitive Bidding Program.” This means that contracted suppliers would not be exempt from this protocol should the final rule come into action.
The proposal goes on to indicate that because of the existing PMD Demonstration Program, PMDs would be excluded from the initial rulemaking – but this could be revisited once the original Demonstration has ended. The current PMD Prior Authorization Demonstration is active in seven states and not slated to expire until August 31, 2015. A proposal to expand that program into 12 additional states is already in the works as of April 4, 2014. The comment period for that proposal closed on April 18, 2014, with all comments in favor of an expansion.
For PARs that are denied or non-affirmed, the supplier would not be limited (based on this proposal) by a specific number of times that a request can be submitted for re-examination. The DME MAC would have 20 days to review the resubmission before rendering a decision.
The comment period for this proposal is open until 5pm Eastern Time on July 28, 2014. Suppliers that wish to submit comment can do so using this link: http://www.regulations.gov/#!submitComment;D=CMS-2014-0070-0001
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