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David McGill Blogger

Prior Authorization for Prosthetics: Final Rule Published

Posted by David McGill | December 30, 2015

Medicare has published its final rule titled "Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies." In the interest of clarity, we begin with the key takeaway: 

While CMS will implement a prior authorization program at some point in the future, when it starts, what items are subject to prior authorization, and how the program actually works all remain undefined. CMS has announced that it will provide answers to all of these key questions in future "subregulatory guidance."

With that overview in mind, did the final rule tell us anything? Here are the 6 things you need to know:

  1. Timelines for Medicare to consider prior authorization requests will not be any longer than those proposed in the original draft rule. This means that for non-expedited requests, the timeline for Medicare to respond to an initial request for authorization will be 10 days. The timeline for Medicare to respond to a resubmission following an initial non-affirmation would be 20 days. Medicare rejected the suggestion that failure to respond to a prior authorization request within the still-to-be-determined final timeline should result in automatic approval of the claim. In other words, if Medicare's contractors fail to provide a response within the deadline, they are not subject to any penalty.

  2. Medicare has identified the universe of items potentially subject to prior authorization. Currently, 84 L codes describing prosthetics are included on the master list. An as-yet unidentified subset of this master list will later be selected for prior authorization. ​To see the complete list of prosthetic L codes potentially subject to prior authorization, go to page 43 of the final rule.

  3. Medicare has indicated that it may roll out prior authorization on a limited geographic basis initially. 

  4. Denial of a prior-authorization request will not be appealable. If your prior authorization request gets denied, you have two options: (a) continue resubmitting as many times as necessary to get the authorization; or (b) deliver the item to the patient and submit the claim for payment without getting authorization, which will result in a denial and trigger your right to the multi-step Medicare appeal process.

  5. Medicare dismissed comments suggesting that the prosthetist's notes and records should independently be permitted to justify medical necessity, instead restating the requirement that prosthetists obtain corroboration from other providers.

  6. Medicare acknowledged that prior authorized claims "will be afforded some protection from future audits, both pre- and post-payment." However, prior authorization will not act as a barrier to fraud or inappropriate utilization investigations.

What does this mean for you?

With so much information still in flux and yet-to-be-published in future subregulatory guidance, there is not much you can do at this time to prepare. Our best advice is to be aware that prior authorization is coming. Confirm that all of your documentation practices are first-rate and that you're complying with all Medicare coverage and payment requirements.

We will keep you updated as new information becomes available.

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