[blind-democracy] FW: CMA Alert: DMEPOS Final Rule; News from the Office of Mean Spirited Policies
- From: "Bob Hachey" <bhachey@xxxxxxxxxxx>
- To: <blind-democracy@xxxxxxxxxxxxx>
- Date: Wed, 06 Jan 2016 21:43:24 -0500
From: communications=medicareadvocacy.org@xxxxxxxxxxxxxxxxxx
[mailto:communications=medicareadvocacy.org@xxxxxxxxxxxxxxxxxx] On Behalf Of ;
The Center for Medicare Advocacy
Sent: Wednesday, January 06, 2016 5:11 PM
To: bhachey@xxxxxxxxxxx
Subject: CMA Alert: DMEPOS Final Rule; News from the Office of Mean Spirited
Policies
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About
_____
* CMS Final Rule for Prior Authorization Process for Certain Durable
Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
* New Feature! News from the Office of Mean Spirited Policies (OMSP)
_____
2016 National Voices of Medicare Summit & Senator Jay Rockefeller Lecture
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April 1, 2016
8:30 am – 5:00 pm
Kaiser Family Foundation Barbara Jordan Conference Center
1330 G Street, NW
Washington, DC 20005
Early-Bird Summit Registration: $175 (Save $50)
Celebrating 30 years of advocacy, this event will connect leading experts and
advocates to discuss best practices, challenges and successes in efforts to
improve health care, long-term services and supports, and quality of life for
older people and people with disabilities.
CMS Final Rule for Prior Authorization Process for Certain Durable Medical
Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
Effective February 20, 2016, CMS has created a prior authorization process for
certain DMEPOS before they can be approved for Medicare payment. Items subject
to prior authorization will be identified on a Master List. According to CMS,
there will be no new documentation requirements, but prior authorization will
help ensure that applicable coverage, payment, and coding rules are met before
equipment or supplies are issued. Data released from CMS, however, raises
concerns that this rule creates impediments to beneficiary access to reasonable
and necessary DMEPOS.
In supporting prior authorization in the new rule, CMS relies on a prior
authorization demonstration program in which monthly expenditures decreased
over a three-year time period from $12 million to $3 million in the program’s
original seven states, and from $10 million to $2 million in the program’s
twelve additional expansion states.[1]
Those are payment decreases of 70% to 80%. CMS indicates that those substantial
decreases were possible because prior authorization stops payment for equipment
and supplies that are “frequently subject to unnecessary utilization.”[2] Is it
possible that a 70% to 80% decrease in payments (translate to a decrease in
approval for equipment and supplies) correlates to a similar amount of fraud in
the program? If so, that would be a win-win for Medicare and for beneficiaries
as CMS should address fraud and only pay legitimate claims. Unfortunately, the
rate of fraud is closer to 8% than 80%. According to the Federal Register, “for
the 2014 reporting period, 92 percent of the DMEPOS improper payment rate is
attributed to insufficient documentation.”[3] Insufficient documentation is
often a simple mistake in the process of documenting the need for the equipment
or supply: a doctor leaves off a date, or a therapist doesn’t complete a field.
These are clerical errors, not fraud. This distortion of the facts by CMS, and
the reports issued by the Office of the Inspector General (OIG) and the
Government Accountability Office (GAO), concern beneficiary advocates when it
comes to implementation of the prior authorization program.
Advice to Beneficiaries:
* Understand which items will be subject to prior authorization. A subset
of the Master List will include items that require prior authorization. Other
items on the list, “may” be subject to prior authorization. The initial items
are yet to be published.
* Sufficient documentation is key. Legitimate prior authorization
requests will only result in obtaining equipment and supplies when the
paperwork is error-free, legible, and complete. Whenever possible have the
prior authorization reviewed by multiple people before submitting it.
* Monitor the maximum prior authorization timeframes established by the
rule. 10 business days for initial review, 20 business days for re-submissions.
There are unlimited re-submissions, but, unfortunately, no appeal rights.
* Know that there is a process for an expedited request for prior
authorization. Documentation must be submitted with the request that indicates
how the life or health of the beneficiary will be seriously jeopardized without
an expedited review. How CMS will define “seriously jeopardized” remains to be
seen.
Possible Pros and Cons of the Prior Authorization Rule
Pro
Con
There are specified review timeframes.
Beneficiaries may see delays in access.
A beneficiary may have greater confidence of coverage before the item is
ordered.
The time to review may be doubled for re-review – even for a simple clerical
error. There is no appeals process.
Questionable billing practices may be prevented.
Beneficiaries may be dependent upon providers and suppliers to ensure the
paperwork is correct.
The system may ultimately be made more efficient for all by encouraging careful
and correct legitimate requests for coverage.
What exactly is subject to prior authorization, and what is not, is currently
unclear.
CMS plans to issue specific Prior Authorization guidance through sub-regulatory
communications. The Center for Medicare Advocacy will monitor these
communications and the Prior Authorization program’s implementation.
In the event beneficiaries encounter any challenges or difficulties with the
Prior Authorization process, the Center for Medicare Advocacy appreciates being
apprised. Please email your comments to <mailto:DMEPOS@xxxxxxxxxxxxxxxxxxxx>
DMEPOS@xxxxxxxxxxxxxxxxxxxx.
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New Feature!
News from the Office of Mean Spirited Policies (OMSP)
Image removed by sender.Occasionally the Center for Medicare Advocacy hears of
a rule, policy or practice that is so contrary to common sense and caring, it's
hard to believe. So we decided how better to react than to share them.
Today is the first in an as-needed series, to be posted when we come across one
of these hard-to-believe notions.
We welcome your submissions for this feature. If you know of a rule, policy or
practice that seems too startling to be true, let us know at
Communications@xxxxxxxxxxxxxxxxxxxx and we will consider sharing it here.
Mean Spirited Policy #1:
<http://org.salsalabs.com/dia/track.jsp?v=2&c=QKQyF7GplsmS9ZcPlz88uqI47ALRTH8Q>
National Coverage Determination (NCD) for White Cane Use by a Blind Person
(280.2)
Per this rule, Medicare will not cover white canes because they are “more of an
identifying and self-help device rather than an item which makes a meaningful
contribution in the treatment of an illness or injury.”
Why limit someone's ability to have a self-help device? Especially since
Medicare will cover other canes used to help ambulation. How can one support a
coverage prohibition for white canes used to increase the independence of
people who are blind? (Kudos to those who use them!)
We urge Medicare to rescind this restrictive rule and provide coverage for
white canes.
- top -
________________________
[1]
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https://www.federalregister.gov/articles/2015/12/30/2015-32506/medicare-program-prior-authorization-process-for-certain-durable-medical-equipment-prosthetics.
[2] Id.
[3] Id.
_____
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