This morning I read over the proposed rules of prior authorization sent out in the ABC News Alert. I found it to be quite shocking and “well documented” on the high rate of improper payments. It looks that we will have a hard time fighting this one unless the improper payment rates can be defended.
One thing that struck me was the even greater responsibility the Practitioner and Physician will have to gather documentation quickly and accurately about the patient. Currently, the financial burden of insufficient documentation is taken squarely on the shoulders of the Practitioner and the patient is serviced weather good documentation is provided or not.
If the new rules are implemented, the patients quality of care will be dependent on our ability to efficiently gather documentation in a timely manner and submit to Medicare or a contractor for prior authorization.
The document states:
“The proposed prior authorization process would not create new clinical documentation requirements. Instead, it would require the same information necessary to support Medicare payment, just earlier in the process. This would ensure that all relevant coverage, coding, and clinical documentation requirements are met before the item is furnished to the beneficiary and before the claim is submitted for payment” (Pg 30520)
The logistics of gathering this documentation and submitting has to happen before the 10 day reply period starts. How long does it take to gather and review necessary physicians notes and other documents before you are ready to submit? A day, maybe two, maybe a week sometimes?
My concern is that Practitioners and Physicians will be held responsible for the adverse effects of a denied prior authorization if our documentation is determined to be insufficient.
So a theoretical situation could be a Patient needs a postoperative TT dressing (L5400). Documentation for prior authorization is sent to Medicare and denied for lack of supporting documentation submitted by the provider. Patient is not given a protective rigid dressing and falls that evening and requires a second surgery. Does the failure to provide the rigid dressing fall on the shoulders of the practitioner because they did not provide proper documentation. There will very likely be a paper trail stating the authorization was denied due to insufficient documentation and according to the reports sited DME suppliers only correctly bill 44% of the time. I think this could be a liability that many Practitioners would not be happy to accept and the lawyers will.
From a more mundane angle, this is also placing a Practitioner between the patient and there device. If prior authorization is not given for improper documentation by Medicare, we will be the ones the patient sees as not doing our job. Again if we apply the current audit rates we are going to be looking very bad, very often.
Just something to think about, Don’t know if I am way off base about this, but a little food for thought.
Joe Young, CPO
