Medicare payment for some physician services may be impacted by prior authorization

Five hospital outpatient department (OPD) services will require prior authorization as a condition of Medicare payment beginning July 1: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation.

While only the hospital OPD service will require prior authorization, the Centers for Medicare & Medicaid Services (CMS) is reminding physicians and others who perform services in the hospital OPD setting that claims related to or associated with these OPD services will not be paid if the OPD service requiring prior authorization is not eligible for payment.

These related services include physician services. Only associated services performed in the OPD setting are affected. Depending on the timing of claim submission for any related services, claims may be automatically denied or denied on a post-payment basis.

For more information, you can view the related final rule as published in the Federal Register and the Prior Authorization for Certain Hospital OPD Services page on the CMS website. You can also send questions to OPDPA@cms.hhs.gov.

— Kent Moore, Senior Strategist for Physician Payment at the American Academy of Family Physicians

Posted on Jun 15, 2020 by Kent Moore