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CMS’s proposed rule on prior authorization

July 22, 2014

As you may know, CMS has proposed a “prior authorization” process for prosthetic reimbursements. At first, this sounds like a good idea, but in discussions with our fellow members of the O&P Alliance*, we have come to see there are major concerns surrounding this rule.

The Alliance is drafting joint comments to submit to CMS, and we are reaching out to encourage you to comment, as well.

Many had hoped that a prior authorization process would be a helpful tool for establishing coverage, as it is with many private insurers. Instead, the proposed CMS prior authorization process mandates the existing additional documentation requirements (ADR) that we see today in the RAC and Prepay audits for prosthetics — without providing any appeal rights. Therefore, the prior approval proposal could play out as a 100% RAC audit prior to claim submission – again, without any appeal rights.

During the comment period, the O&P profession has an opportunity to point out what services should be subject to prior authorization, and what that process should look like should it be implemented. Among the requirements that must be included in the process:

  1. Prior authorization must constitute a guarantee of Medicare payment.
  2. A prior-authorized claim must not be subject to double jeopardy through later Pre- or Post-Payment Audits, and all RAC audits on prosthetic claims should be discontinued.
  3. Prosthetic service carve-outs are required in the interest of timely care — IPOPs, temporary prostheses, lower limb prosthetic base codes, and socket replacement should be exempt.
  4. An appeals process must be established.
  5. Recognition of the validity of the Prosthetist’s assessment and clinical notes in defining medical necessity for a prosthetic service.

AOPA has created a convenient vehicle to submit comments about this proposed rule. It takes less than two minutes, and they have graciously agreed to share the tool with BOC.

Click here to submit a pre-written comment.

The deadline for comment submission is July 28, 2014, so please act now!

Thank you for taking action on this important matter!

 

*The members of the O&P Alliance are BOC, ABC, AOPA, the Academy, and NAAOP. For more information see: www.oandpalliance.org.