Thirty-one new items of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) will join two existing items of DMEPOS on the Center for Medicare and Medicaid Services (CMS) Master List of Items Frequently Subject to Unnecessary Utilization, requiring prior authorization as a condition of payment. All these 33 DMEPOS items are types of power wheelchairs.
In a June 5, 2018, Federal Register announcement, CMS stated the goal of prior authorization is to reduce fraud, waste, and abuse, while protecting access to care. In previous Federal Register postings, however, CMS stated that 92% of the DMEPOS improper payment rate is attributed to “insufficient documentation” rather than fraud, waste, and abuse. Insufficient documentation is often a simple mistake in the process of documenting the need for the equipment – a doctor leaves off a date, or the therapist does not complete a field. These are clerical errors, not fraud.
For CMS to state that simple mistakes in paperwork result in “unnecessary utilization” of wheelchairs by individuals who legitimately require them for access to mobility is unconscionable. Characterization of the “Master List” as “Items Frequently Subject to Unnecessary Utilization” portends that beneficiaries should engage in proactive measures to ward off prior denial, rather than to assume prior authorization will be approved.
Beneficiaries should be aware of the pros and cons of prior authorization and be fully prepared in order to avoid prior denials.
Possible Benefits of Prior Authorization:
- Beneficiaries may have greater confidence of coverage before the item is ordered.
- Questionable billing practices may be prevented.
- There are specified review timeframes (ten business days for initial review, twenty business days for resubmissions).
- The system may be made more efficient for all by encouraging careful and correct legitimate requests for coverage.
Possible Problems with Prior Authorization:
- Beneficiaries may see delays in access, and/or unfair denials of access, to services and equipment.
- The time to review may be doubled for re-review, even for a simple clerical error.
- There is no appeals process. (Note, however: While the prior authorization process allows unlimited prior authorization submissions, for non-affirmative prior authorization decisions, if a supplier submits a claim for payment determination to Medicare for DMEPOS, and that claim is denied, beneficiary appeal rights are available).
- Beneficiaries may be dependent upon providers and suppliers to ensure the paperwork is correct and error-free.
How to Minimize/Avoid Denials:
- Understand which items will be subject to prior authorization, effective September 1, 2018. The list is located at https://federalregister.gov/d/2018-11953.
- Ensure sufficient documentation. Evidence must include information that the item complies with all applicable Medicare coverage, coding, and payment rules. The paperwork must be error-free, legible, and complete. Whenever possible, have the prior authorization request reviewed by multiple people before submitting it.
- Monitor the maximum prior authorization timeframes established by the rule. The timeframes are ten business days for initial review, twenty 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.
If a beneficiary encounters difficulties with the prior authorization process, please inform the Center for Medicare Advocacy. Please email your stories or comments to DMEPOS@MedicareAdvocacy.org.
June 7, 2018 – K. Holt
 Items coded K0856 and K0861 are currently subject to prior authorization.