Durable Medical Equipment, Prosthetics, Orthotics, Supplies

Proposed Rule on Prior Authorization Process Draws AAFP Rebuttal

July 30, 2014 09:44 pm News Staff

The AAFP recently responded to a CMS proposed rule on prior authorization for certain durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) with sharply words regarding certain provisions that seem to contradict one another.

[Elderly woman using walker]

In a July 24 letter(3 page PDF) to CMS Administrator Marilyn Tavenner, M.A., AAFP Board Chair Jeff Cain, M.D., of Denver, called on CMS to address certain discrepancies in the proposal and to "accurately account for the burden on physicians" before adopting a final rule.

In the letter, Cain first acknowledged that the issue of DMEPOS had "an unfortunate history of being a haven for those wishing to commit Medicare fraud and abuse."

Indeed, Cain pointed out that in 2012, DMEPOS claims had a 66 percent improper payment rate and accounted for nearly 20 percent of improper Medicare fee-for-service payments.

"The AAFP supports strong and appropriate efforts to prevent this sort of fraud, waste and abuse," said Cain. However, family physicians, their patients and DMEPOS suppliers would most benefit from a prior authorization process that "helps determine appropriate care based on the patient's established coverage."

Story Highlights
  • The AAFP recently responded to CMS' proposed rule on prior authorization for certain durable medical equipment, prosthetics, orthotics and supplies.
  • The AAFP said it supported appropriate efforts to prevent fraud, waste and abuse, but contended that CMS was instead using prior authorization as an enforcement mechanism.
  • The AAFP called on the agency to provide appeal rights for prior authorization decisions.

Unfortunately, he added, it appears that CMS "increasingly utilizes prior authorizations for DMEPOS items as an enforcement mechanism."

Furthermore, "CMS treats all improper payments immediately as fraud or abuse when inadvertent and honest billing mistakes or coding errors do occur with medical practices," said Cain.

The AAFP is concerned that, as written, CMS' prior authorization proposal mandates a process for handling some DMEPOS items "without actually providing physicians with appeal rights until the item is furnished and the claim is submitted and denied," he said.

Cain took issue with CMS' definition of "unnecessary utilization" -- described as furnishing items that do not comply with one or more of Medicare's coverage, coding and payment rules -- and noted that Medicare's view of "necessary" could be very different from that of physicians and patients.

He urged CMS to allow evidence-based medicine to "dictate the measure of 'necessity' in medicine."

The Academy also expressed concern with CMS' language regarding provisional affirmations that later could be denied based on technical requirements evaluated after a claim was submitted for formal processing.

"This proposal undermines the original intent of a prior authorization," said Cain. "What good is 'prior authorization' if the supplier and the beneficiary cannot depend upon it?"

Cain urged CMS to simply provide appeal rights for prior authorization decisions rather than forcing suppliers to summit a claim for denial so that appeal rights could be attained. He said the proposed rule would result in "more work for the supplier and CMS and its contractors to get to the same end point -- a first-level appeal."

CMS estimated it would take suppliers about 30 minutes to prepare a prior authorization request, and yet the proposed rule provided no calculation of the time burden on prescribing physicians, Cain noted.

DMEPOS suppliers typically contact the ordering physician for medical record documentation, said Cain, a task that could mean an additional 30 minutes of work for the physician that "should be accounted for in CMS' impact analysis."

Finally, the AAFP argued that the proposed rule would not lighten the administrative burden on physicians and would it not protect DMEPOS suppliers' cash flow because claims could still be denied even after being submitted and receiving provisional affirmation.

Family physicians interested in reading the proposed rule in its entirety can find it in the May 28 Federal Register(www.gpo.gov).

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