If past problems are any indication of how the future might go, a Centers for Medicare and Medicaid Services (CMS) proposal to require prior authorization for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) could "impede or delay access to timely medically necessary care" due to a lack of sufficient infrastructure to efficiently administer the new requirement, according to APTA comments recently submitted to CMS.
In a July 25 letter (.pdf) to CMS Acting Administrator Mary Tavenner, APTA applauds the CMS effort to reduce fraud and abuse with DMEPOS use, but warns that the agency's track record on payment review systems doesn't bode well for fullscale implementation of a plan to mandate authorization reviews for devices and supplies that often require quick patient access. The proposed rule states that CMS contractors will use "reasonable efforts" to issue authorization decisions within 10 days of the receipt of a standard request, or 2 business days for an "urgent" decision. In both cases, APTA points out, the waits "could result in serious decline of a beneficiary's health and safety," particularly if an urgent request is submitted on a Thursday or Friday and a patient must wait over a weekend for a decision.
Matters have the potential to be made worse, APTA suggests, should the CMS contractors lack sufficient expertise and infrastructure to make informed, timely decisions—problems that have cropped up in other payment review systems, most notably in manual medical reviews for patients exceeding $3700 in outpatient therapy services. The association cites federal government reports that point to problems with lack of specificity in denial rationales, "flawed logic" in tracking systems, contractor statements backed by questionable facts, inaccessibility for providers, poor customer service, and lack of clinical expertise.
APTA acknowledges the need for a focus on DMEPOS utilization, but suggests that if CMS chooses to move ahead with a prior authorization system, it do so incrementally, with "a small set of items … tested to determine whether the proposed protocols can be operationalized on the front lines of care delivery before the program is launched nationally."
"APTA recognizes that oversight of DMEPOS utilization is necessary; however, it is of limited value if delays cause detrimental health impacts on beneficiaries or impose additional administrative and financial burdens on providers and suppliers due to operational and technical issues," the letter states. "The prior authorization process should neither delay the provision of care, nor be overly burdensome to providers or patients."
APTA will update its DMEPOS resource webpage when this rule becomes final and the specific DMEPOS items subject to the rule have been selected.
Note: see table 4 of the proposed rule for a list of items that may be chosen for prior authorization.
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