Update on DME Prior Authorization: Final Rule

There’s uncertainty and lot of confusion in the DME Prior Authorization sector since the introduction of the Final Rule by CMS. End Quote

Amarillo, TX (1888PressRelease) November 18, 2017 - CMS with its mid-year introduction of the Final Rule has created waves in the medical and healthcare industry. The Final Rule mandates that prior authorization for DME (selected), prosthetics, orthotics, and supplies (DMEPOS) are subjected to a competitive bidding program. An insight to the Final Rule portrays that DME Prior authorization has been more or less benefitted wit this decision. The Final Rule has been perceived as a step ahead of CMS’s effort to reduce frauds, make the process transparent, and check the rising price of the DMEPOS to an extent.

Final Rule – What and How Does it Affect DME Prior Authorization
According to the Final Rule, Master List of 135 DMEPOS items is being identified based on frequent exposure to unnecessary utilizations. Items that have met the criteria are included in the Master List based on the Items on the DMEPOS Fee Schedule and include the following:
• Items with an average purchase fee of $1,000 or more
• Items with an average rental fee schedule of $100 or more

The Master List items have a validity of 10 years and can be removed earlier if the purchase amount drops below the payment threshold. Even after 10 years, items can remain on the list or be added back to the list subject to prior authorization.

With such a huge change, it is implied that the process for Prior Authorization for DME/DMEPOS items would be more demanding for the in-house staff the physicians, hospitals, labs, healthcare centers etc. as there will be more checks and reviews that include applicable coverage, payment, and coding rules. To speak of coding, let’s check a few updates on Accessory Codes based on the Final Rule. Accessory codes required to make a coverage decision on the base include, but are not limited to, power seating system are shown below in the table.

CODES and Descriptions:
E100: Power seating system combination tilt and recline
E2327, E2328, E2329, E2330: Head control interface
E2322: Multi-switch hand control interface
E2312, E2321, E2373: Joystick other than a standard proportional joystick
E1030: Wheelchair accessory, ventilator tray, gimbaled

So it’s evident that for the time consuming process of DME Prior authorization and the technicalities make things worse. Sensing this issue, more and more providers are in the process to outsource their DME prior authorization to professional prior authorization services. Leading companies like PriorAuth Online charge very low for their services and bring back the revenue are fast, efficient, and have high accuracy level. These services also provide end-to-end practice management and revenue cycle management, the modern necessities that keep the ball rolling. So the presence of DME prior authorization services save the day by answering those!

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