CMS today announced the release of a
DMEPOS final rule that requires a new mandatory preauthorization process for some medical equipment issued to Medicare beneficiaries.
Though the agency hasn't revealed which items will require preauthorization, it has published a "master list" from which those items will be selected.
The rule was first
proposed in May 2014 when CMS, citing concern with fraud and waste in the provision of DMEPOS (durable medical equipment, prosthetics, orthotics, and supplies) to Medicare beneficiaries, suggested a method by which some problematic items might get special scrutiny before they were paid for.
The 121-page final rule establishes a master list of 150 DMEPOS items that will be considered for prior authorization. This list includes items which have an average purchase fee of $1,000 or more or an average monthly rental fee schedule of $100 or more, or which have been the subject of OIG, GAO or other government investigations.
The current master list (pp. 41-47 of the rule) includes several types of power wheelchairs, lower extremity prostheses and additions, the continuous positive airway pressure (CPAP) device (E0601), power mattresses, etc. Listed items will be revisited once a year and when their HCPCS codes change. Items will otherwise remain on the list for at least 10 years unless they disqualify, e.g., drop below the price threshold.
Some items on the master list will be chosen annually for placement on a "Required Prior Authorization List." These items will not be paid for unless full preauthorization with Medicare has been attained. This will include not only receipt of all applicable required Medicare documentation but also medical review by CMS or a contractor resulting in "a decision that provisionally affirms or non-affirms the request." (These bodies would make "reasonable efforts" to communicate their decision "within 10 business days of receipt of all applicable information.")
The first Required Prior Authorization List is not included in the rule; CMS says it will be issued in the Federal Register in 60 days, without rulemaking or a comment period. These prior authorization choices will thereafter be revisited annually. (Certain power mobility devices, which are
already subject to preauthorization in some cases, will not be placed on the list at this time but remain subject to their current rule and may be added to the list later.)
CMS establishes no specific methodology for preauthorization but says it "may consider factors such as geographic location, item utilization or cost, system capabilities, administrative burden, emerging trends, vulnerabilities identified in official agency reports, or other data analysis."