Good Morning,
I would be very interested to hear what the general opinion is of the idea of Medicare issuing DMEPOS prior authorizations? I know that this is a topic of concern and that most providers are being urged by their associations to oppose the idea but I can’t help but think that it could only improve our situation.
With the majority of all prosthetic claims and diabetic shoes now being reviewed for pre-payment audits anyways, if I were a provider I would certainly feel more confident providing services and buying componentry knowing that CMS has already reviewed my documentation and deemed it sufficient (during authorization) rather than being expected to provide a service and then await documentation review to determine whether I will or will not be paid for that service.
Previously it was thought that our biggest concerns were RAC audits but the MAC pre & post payment audits are now far more invasive than any outcome we ever experienced with the RAC audits. Truth be told my clients haven’t seen any RAC audits probably in two years but they are slammed daily with documentation requests and audits from their MAC, with Region B certainly leading the pack.
Coming from someone who spends 80% of their day responding to documentation requests and filing appeals, it would certainly seem to me that providers would benefit from some type of a prior authorization system, if appropriately executed. I would think that the change would have to come with some guarantee that the initial documentation review decision is final so that providers aren’t required to go through the auth process only to have the MAC still put them through the pre-payment audits after services are rendered. Most of the small providers are already short the manpower necessary to respond to these requests and file the necessary appeals, that imposing multiple reviews could put them over the edge. Although this really is no different than what NGS is doing now. They are conducting pre-payment audits for a couple codes on the prosthesis. And then, after the claim pays identifying other codes that they want to complete post payment review of. Still subjecting providers to multiple audits of the same claim but getting around the system by doing it a few separate codes at a time.
I am very interested to hear the opinions of others! I would be happy to compile and repost those opinions. Thanks in advance for your time and for sharing your thoughts!
Sincerely,
Nicole Godwin-Burns
Vice President
Compliance AccountAbility & Training Solutions, LLC
P.O. Box 225
Danville, IN 46122
P: (877) 220-9379
