CMS Final Rule - Changes to the Prior Authorization Process for Durable Medical Equipments (DMEs)

On Dec. 29, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that establishes a prior authorization process for certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items that are frequently subject to unnecessary utilization. CMS has stated that this prior authorization process will help ensure that certain DMEPOS items are provided consistent with Medicare coverage, coding, and payment rules. They believe the final rule will prevent unnecessary utilization while safeguarding beneficiaries’ access to medically necessary care. 

As outlined in the final rule, the prior authorization process will require the same information necessary to support Medicare payment today, just earlier in the process. It will not create new clinical documentation requirements. They believe carrying out  this process earlier will help ensure that beneficiaries are not held responsible for the cost of items that are not eligible for Medicare payment. CMS believes prior authorization is an effective way to reduce or prevent questionable billing practices and improper payments for DMEPOS items. 

See the entire final rule.

Contact: Cheryl Udell, cudell@leadingageny.org, 518-867-8871