Medicare Compliance & Reimbursement

Why some stakeholders believe CMS is unfairly including leg prostheses.

When the Centers for Medicare & Medicaid Services (CMS) finalized the prior authorization final rule for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) items, not all industry stakeholders were overjoyed. In fact, some organizations are expressing serious concerns over the rule, and here are the three major issues:

1. Prior authorization does not guarantee payment. One concern about the final rule is that prior authorization does not equate to a guarantee of claim payment, nor does it eliminate the exposure of the claim to additional audits, according to a Dec. 30, 2015 analysis by the American Orthotic Prosthetic Association (AOPA).

“In the final rule, CMS retains its position expressed in the proposed rule that a denial or prior authorization is not considered an initial determination for a claim of payment and, as a result, will not be appealable,” stated a Jan. 7 analysis by the law firm McDermott Will & Emery (MWE). If you submit a claim for an item without an affirmative prior authorization decision, Medicare will automatically deny payment.

“Therefore, prior authorization is a condition of payment, but does not necessarily guarantee payment,” MWE explained. “Information that is only available after the claim is submitted may result in denial (e.g., duplicate claim, absent or improperly listed delivery date).”

2. The list could arbitrarily include prosthetics with no problems of unnecessary utilization. According to Medicare’s own data, there is not a problem of unnecessary utilization of lower limb prosthetics, the AOPA pointed out.

In fact, the 14-percent reduction in prosthetics payments over the 2010 through 2013 period proves that, AOPA said. Also, Medicare prosthetic patients are 35 percent less likely to receive an advanced tech prosthetic device today than they were only five years ago.

3. Beneficiaries could face unreasonable delays. “AOPA’s primary concern with prior authorization of prostheses is, and always has been, that it will critically delay timely access to the provision of prosthetic devices that are crucial to the rehabilitation needs of Medicare beneficiaries,” the organization stated. The final rule indicated that CMS will use sub-regulatory processes to determine appropriate timelines for making prior authorization decisions.

Also: “These sub-regulatory processes are inherently arbitrary in that they do not allow for public input and/or comment regarding their appropriateness,” AOPA lamented. “AOPA remains concerned that prior authorization of any kind will only serve to hinder the delivery of medically necessary prosthetic care within reasonable timeframes.”