How to head off DME prior authorization troubles

A new federal rule that requires prior authorization for certain durable medical equipment could lead to extra paperwork for physicians and frustration for patients, according to an article from Family Practice News.

Under the final rule, the Centers for Medicare & Medicaid Services (CMS) has created a master list of 135 durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) items that may require prior authorization from the Medicare program because they cost an average of at least $1,000 to purchase or $100 a month to rent, FierceHealthFinance reported previously. They include items such as powered wheelchairs, which have been the target of antifraud investigators recently, and a variety of prosthetic limbs and sockets.

The new rule requires that all relevant coverage, coding and clinical documentation is provided before the supplier furnishes the equipment to the patient and before the claim is submitted for payment. This may mean patients will wait longer to get their equipment--a dynamic that could lead to tension without proper communication and preparation.

"Oftentimes, there's the finger-pointing exercise that occurs when things don't happen quickly enough and patients are unhappy," Yul D. Ejnes, M.D., an internist in private practice and a past chair of the American College of Physicians Board of Regents, told Family Practice News. "It just adds to the temperature of the environment, which is already pretty high because of patients unhappy about increasing copays and deductibles and everything else."

To help keep this friction to a minimum, physicians should identify the DMEPOS items they order or prescribe most often and engage with suppliers early to ensure they understand what kind of documentation will be needed, Wanda Filer, M.D., president of the American Academy of Family Physicians, told the news outlet.

To learn more:
- read the article
- read the CMS final rule (.pdf)

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