We talked to Lisa Maciejewski-West -- president and owner of Gold Star Medical Business Services in San Angelo, Texas, and a faculty member of the Practice Management Institute (PMI) – about the new DMEPOS final rule and its possible impact on providers.
She expects the pre-authorization scheme will be troubled and "revisited and revised until a workable solution is found."
As we wrote in our PBN story, the rule issued Dec. 29 establishes a “master list” of 150 DMEPOS (durable medical equipment, prosthetics, orthotics and supplies) items, most of them big-ticket items ($1,000 or more per unit) or prior subjects of federal investigations, from which an unknown number will be chosen in February for mandatory preauthorization, which “will require applicable documentation to be submitted for review before an item is delivered to the beneficiary."
Here are some of Maciejewski-West's predictions for this arrangement:
Suppliers pull back. Maciejewski-West believes DME suppliers will "be looking for items that can be used by physicians and beneficiaries that would fall under the $1,000 purchase threshold" for the master list. That way they have a better chance of avoiding payment delays that would be caused if any of them wind up on the pre-authorization list.
An increase in referrals from general practice physicans to specialists for those patients who need supplies. "GPs may not have the ability to provide enough diagnostic workup necessary to justify medical necessity," explains Maciejewski-West.
Eventual changes to the process. The new system "definitely adds administrative burdens to physicians' offices," says Maciejewski-West, and after awhile this will cause CMS to "revisit and revise [the process] until a workable solution is found." CMS may try to substitue more audits for providers who exceed a threshold of DME referrals/recommendations or random checks on DME authorizations for quality-control purposes.
Or they may hang onto the process, but speed it up to avoid timely-delivery issues. "I would envision a process where authorizations are submitted through some type of online portal and a provisional affirmation is made at that point, within 24-48 hours," says Maciejewski-West. Some providers may then be asked to submit more documentation, such as clinical notes, before the item is released.