Thursday, May 19, 2022

VIEW OUR VIDEO and Update on Prior Authorization and Breaking VA News


Please see the link below for our video webcast. Also, at the bottom of this
written update see the link so you may register for our July 23rd all-member
public policy conference call.

Authorization and Breaking VA News

Much has occurred since last month’s update on the same two issues impacting
orthotics and prosthetics; prior authorization and leadership at the
Veterans Administration. The NAAOP is currently working-along with the O&P
Alliance-to draft a comprehensive response to CMS’ proposed rule, Medicare
Program; Prior Authorization Process for Certain Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies (DMEPOS) Items. All comment letters are
due July 28, 2014 and we encourage all NAAOP members to submit comments
consistent with NAAOP’s position. (A draft response will be posted on
NAAOP’s website by July 15th.)

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. 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 ALJ which, of
course, 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 an HHS 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 and, in
NAAOP’s view, overstates the risk of overutilization of lower limb

Nonetheless, 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. NAAOP also supports a demonstration project or
pilot program to ensure that prior authorization of certain lower limb
prosthetics 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. We will continue to keep the members of NAAOP
informed as we continue to draft and finalize comments to the proposed rule.

Veterans Administration: 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 and a West Point graduate. As
he 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. 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.

Please visit our website at:


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7th Floor

Washington, DC 20005-1700

e-mail: [email protected]

(800) 622-6740

(202) 624-0064 Phone

(202) 785-1756 Fax


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