The following is from a CMS bulletin received May 22, 2014---
The
Centers for Medicare & Medicaid Services today announced plans to expand a
successful demonstration for prior authorization for power mobility devices,
test prior authorization in additional services in two new demonstration
programs, and propose regulation for prior authorization for certain durable
medical equipment, prosthetics, orthotics, and supplies. Prior authorization supports the administration’s ongoing efforts to
safeguard beneficiaries’ access to medically necessary items and services,
while reducing improper Medicare billing and payments. The proposed rule is
estimated to reduce Medicare spending by $100 to $740 million over the next ten
years.
“With
prior authorization, Medicare beneficiaries will have greater confidence that
their medical items and services are covered before services and supplies are
rendered. This will improve access to services and quality of care,” said CMS
Administrator Marilyn Tavenner.
The
announcement builds upon lessons learned from the Medicare Prior
Authorization of Power Mobility Device Demonstration. Launched in 2012, the demonstration established a prior authorization
process for certain power mobility devices. Based on September 2013 claims
data, monthly expenditures for certain power mobility devices decreased from $12
million in September 2012 to $4 million
in August 2013 across the seven demonstration states (California, Florida, Illinois,
Michigan, New York, North Carolina, and Texas) with no reduction in beneficiary
access to medically necessary items.
CMS
seeks to leverage this success by extending the demonstration to an additional
12 states. These states include Arizona, Georgia, Indiana, Kentucky,
Louisiana, Maryland, Missouri, New Jersey, Ohio, Pennsylvania, Tennessee, and
Washington. This will bring the total number of states participating in the
demonstration to 19.
CMS also proposes to establish a
prior authorization process for certain durable medical equipment, prosthetics,
orthotics, and supplies items that are frequently subject to unnecessary
utilization. Through a proposed rule, CMS will solicit public comments on this
prior authorization process, as well as criteria for establishing a list of
durable medical items that are frequently subject to unnecessary utilization
that may be subject to the new prior authorization process. The proposed rule is currently on display at https://www.federalregister.gov/public-inspection and will be published in the Federal Register on May
28, 2014. The deadline to submit comments is July 28, 2014.
CMS will launch two payment model
demonstrations to test prior authorization for certain non-emergent services
under Medicare. These services include hyperbaric oxygen therapy and repetitive
scheduled non-emergent ambulance transport. Information from these models will
inform future policy decisions on the use of prior authorization.
Prior authorization does not create
additional documentation requirements or delay medical service. It requires the
same information that is currently necessary to support Medicare payment, but
earlier in the process. CMS believe prior authorization is an effective way to
ensure compliance with Medicare rules for some items and services.
For more information, go to: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Overview.html.
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