Starting next month, Medicare won’t pay for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) without prior authorization. The regulation could mean headaches for doctors in the form of extra paperwork and frustrated patients.
“Our initial reaction is one of concern,” said Dr. Wanda Filer, president of the American Academy of Family Physicians. “This new rule could prompt DMEPOS suppliers to request additional documentation from ordering/prescribing physicians to support the suppliers’ requests for prior authorization. Such requests could lead to administrative hassles for physicians.”
Dr. Wanda Filer
Under the new requirement – effective Feb. 29 – prior CMS authorization will be required for certain DMEPOS items that are frequently subject to “unnecessary utilization,” according to a Dec. 29 announcement. The prior authorization process requires the same information currently necessary for Medicare payment, but will happen earlier in the process.
The early evaluation will assure that all relevant coverage, coding, and clinical documentation is provided before the equipment is furnished to the patient and before the claim is submitted for payment. CMS hopes the prior review will reduce improper payments for DMEPOS.
Not every piece of durable medical equipment will be subject to prior authorization; instead, CMS will prescreen items from its master list of 135 costly and overprescribed items, especially those with an average purchase price of more than $1,000 or rental fee of $100. The complete master list was published within CMS’ final rule in the Federal Register. CMS will publish a “required prior authorization list” 60 days before implementation.
The final rule primarily impacts vendors paid by Medicare to supply durable medical equipment to patients, said Dr. Yul D. Ejnes, an internist in private practice and a past chair of the American College of Physicians Board of Regents. The prescriber is responsible for meeting all Medicare coverage, coding, and payment rules. However, doctors will likely be indirectly affected because of the clinical documentation required for CMS approval, Dr. Ejnes said.
Dr. Yul Ejnes
“The documentation requirement could be burdensome depending on how DME vendors interpret the regulations, and then the whole issue of increasing the amount of chart documentation that’s going out to various places raises some concern,” Dr. Ejnes said in an interview. “Even though it may all be covered under HIPAA, [there’s] the issue of content in the notes that’s irrelevant to the DME request and how we handle that. Do we need to start redacting notes to meet the documentation requirements for prior authorization?”
The new requirements also may mean that patients wait longer for needed equipment, Dr. Ejnes added. “Oftentimes, there’s the finger-pointing exercise that occurs when things don’t happen quickly enough and patients are unhappy. “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 prepare for the rule, 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, Dr. Filer recommended.
“If the physician understands upfront what Medicare requires and is able to provide it to the DMEPOS supplier[s] at the time the DMEPOS items are ordered/prescribed, that may save time on the back-end preventing or otherwise dealing with additional documentation requests from the DMEPOS supplier[s] in support of prior authorization requests,” she said.
Be extremely thoughtful about prescribing durable medical equipment and make sure that equipment orders are placed that meet the patient’s needs rather than their desires, Dr. Ejnes recommended. In addition, it’s helpful for practices to consider work flow and how to efficiently respond to document requests. In some cases, office staff can locate records or precomplete basic information on forms, he said.
“Figure out a way to respond to these in terms of who in the office will take the first pass if there’s a form to fill out,” he said. “Be aware that there may be some delays in getting patients what they need. Some of these items are not emergency items. Educate patients to the fact that there’s a couple steps between writing the prescription and them picking up the item.”
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