On June 17, the Centers for Medicare and Medicaid Services held an Open Door Forum conference call to discuss the proposed rule to expand the current prior authorization demonstration project for power mobility devices and initiate a prior authorization program for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), including certain prosthetic items. The American Orthotic and Prosthetic Association (AOPA) participated in the call, and reported on it as follows:
The portion of the call that addressed the proposed prior authorization for certain prosthetic items was mainly informational as the Centers for Medicare & Medicaid Services (CMS) stated that it could not address many specific issues during an open comment period for a proposed rule. Two separate CMS representatives stated that claims that receive an affirmative prior authorization decision generally would not be subject to future audit activity, except in situations where specific patterns of fraud and/or abuse are present.
AOPA said that these statements appear to be encouraging, but it remains concerned that the proposed rule makes no mention of a prior authorization affirmation having any impact on the eligibility of the claim for future audit. Further, while the statements were made in a public forum, they must not be considered valid unless they are published in the final rule after the comment period ends on July 28.
AOPA said it is in the process of drafting its comments on the proposed rule and will continue to press CMS to eliminate, as part of the written final rule, the potential for future audits as a condition of any prior authorization program. Without some guarantee that prior authorization will eliminate future audits, CMS is only adding an additional step in the already over aggressive Medicare audit process, AOPA said.