NAAOP position on prior authorization

NAAOP position on prior authorization

Paul E Prusakowski

7/18/2014

I write as President of NAAOP to offer my comments after reading this string of messages on the issue of prior authorization for Medicare lower limb prostheses. First off, it is clear that many individuals in the field believe that prior authorization is preferable to a world where post-payment audits leave prosthetists holding the bag. But there are real concerns with the rule as currently proposed by CMS. NAAOP, along with the O&P Alliance organizations, share these concerns. We are in the midst of finalizing a joint response to CMS on the prior authorization proposed rule where we raise these concerns but propose a series of changes that would make the process much more workable for practitioners and patients. If we simply support what CMS has proposed as is, we can expect few of our concerns to be considered by CMS when it issues its final rule.

We believe that, if prior authorization is applied to O&P patient care, it should mean that once the prior authorization is approved, CMS and ALL of its contractors, including RACs, should be prevented from questioning the medical necessity of the claim. It is reasonable for CMS to reopen claims to see if they were incorrectly billed, or filed in duplicate, or did not demonstrate that delivery of the prosthesis occurred, but they should not be able to question for a second time the medical necessity of the claim. This is an important protection for the O&P field that NAAOP, and the Alliance, is fighting for (of course, we are still working on achieving consensus amongst the five organizations on our joint comments on prior authorization).

We also have questions as to the documents that will be required for a CMS contractor to approve a prior authorization request. If they require extensive physician documentation and ignore the prosthetist's clinical notes, that is a major problem that will delay, and ultimately deny, patient care. This is an important issue not addressed by the proposed rule, so our joint comments will press CMS to clarify what is required to demonstrate medical necessity.

These are just a few of the issues that need to be addressed in a final rule. The reality is that prior authorization will likely be applied to certain aspects of O&P care as a result of this rule. But NAAOP and its Alliance partners are working to get the best final rule possible.

And make no mistake, our concerns about prior authorization stem from CMS's tendency to apply DME solutions to orthotic and prosthetic patient care. Prior authorization started with Medicare coverage of power wheelchairs and now they are proposing to apply it to lower limb prostheses based on government reports that, they say, establish this as an area with a lot of overutilization. If we were to welcome prior authorization as proposed, we would be essentially accepting CMS's viewpoint on this, and we most certainly do not.

The fact is that CMS has plenty of options to limit overutilization-other than prior authorization-that NAAOP and its Alliance partners have been pushing CMS to adopt for several years. We have been pressing CMS to implement federal law that links the right to bill Medicare for custom orthotics and prosthetics with O&P licensure and accreditation. We have been asking CMS to treat O&P separately from DME for years. We have been demanding that CMS recognize the clinical notes of the prosthetist/orthotist as part of the medical record when determining the medical necessity of O&P patient care.

We encourage all O&P practitioners to submit comments to CMS on the proposed rule on prior authorization, but before you do, we ask you to consider these comments, and the viewpoints of other O&P Alliance organizations. We will be posting the joint Alliance comments very soon and encourage you to adopt our positions so we can ensure CMS publishes the best final prior authorization rule possible. Thank you.

Paul E. Prusakowski, CPO, FAAOP
NAAOP President