The National Association for the Advancement of Orthotics and Prosthetics (NAAOP) released a new webcast about prior authorization and news from the U.S. Department of Veterans Affairs. A summary follows:
NAAOP General Counsel Peter Thomas, JD, said NAAOP is currently working-along with the O&P Alliance-to draft a comprehensive response to the Centers for Medicare & Medicaid (CMS) proposed rule, “Medicare Program; Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items.” Comments to CMS are due by July 28, and NAAOP encourages its members to submit comments consistent with NAAOP’s position. (A draft response will be posted on the NAAOP website by July 15.)
Under the proposed rule on prior authorization for, among other things, certain lower-limb prostheses, the O&P provider obtains a “provisional affirmation” prior authorization decision and then proceeds to provide the services and bill the Medicare program, Thomas said. If CMS denies the prior authorization request, the supplier may not appeal the determination but may resubmit the prior authorization request multiple times. If a supplier submits a final claim without obtaining prior authorization, the claim will be denied and the supplier may then appeal the decision to an Administrative Law Judge (ALJ), which could take years to resolve. CMS states in the proposed rule that it will make “reasonable efforts” to communicate its prior authorization decision within a standard timeframe depending on whether the request is an initial request, a resubmitted request, or a request for expedited review. CMS cites a U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) report as a reason for including in the proposed rule certain lower-limb prostheses that have an average payment threshold of $1,000 or more. However, this OIG report is significantly flawed, Thomas said, and in NAAOP’s view, overstates the risk of overutilization of lower-limb prostheses.
Nonetheless, Thomas said NAAOP has serious concerns with prior authorization and there is little in prior authorization that benefits patients directly. However, given aggressive Recovery Auditors and lengthy ALJ appeal delays, prior authorization for certain, limited prosthetic components may be the better option, assuming major safeguards are added to the final rule. For instance, once a prior authorization request has been approved, CMS should be obligated to pay that claim and should be barred from reopening the claim after the care has been provided to question whether the documentation supports medical necessity, Thomas said, adding that NAAOP also supports a demonstration project or pilot program to ensure that prior authorization of certain lower-limb prostheses does not compromise patient care. Finally, CMS must delineate in the final rule the specific types of documentation it expects in the prior authorization request.
NAAOP said it will continue to keep its members informed as it continues to draft and finalize comments to the proposed rule.
As for the VA, after the resignation of VA Secretary Shinseki, multiple hearings in both the House and Senate, and passage of VA reform bills in both houses of Congress, President Obama announced the nomination of a new Secretary of Veterans Affairs, Bob McDonald, the former CEO of Procter & Gamble, Cincinnati, Ohio, and a West Point, New York, graduate. As McDonald undergoes Senate advice and consent, a House-Senate conference committee is negotiating a compromise bill that would allow many veterans to opt for government-subsidized care outside the VA system, Thomas said. This is similar to one of the key provisions under H.R. 3408, the Injured and Amputee Veterans Bill of Rights, which clarifies that veterans have a right to choose an O&P practitioner of their choice.