prior authorization for prosthetics
Herb Shalant
Description
Collection
Title:
prior authorization for prosthetics
Creator:
Herb Shalant
Date:
7/18/2014
Text:
-----Original Message-----
From: Herb Shalant [mailto:<Email Address Redacted>]
Sent: Friday, July 18, 2014 11:16 AM
To: 'Paul E Prusakowski'
Cc: O & P List Serve ( <Email Address Redacted> )
Subject: RE: [OANDP-L] NAAOP position on prior authorization
Paul and Fellow List-Serve readers,
I went through the entire list of Lower Extremity Prosthetic codes (89 in
total as proposed ) and found that with the exception of 3 codes (L5859, L
5961, and L 5969 which are advanced knee, hip and ankle components with
recent inclusion into the code set) they included every prosthetic code
that exists that reimburses over $1000 in Region A where I practice. They
included 5 codes that reimburse under $1000 in my Region (L 5606, L5718,
L5722, L5816, L5848 ). These codes reimburse at $998, 987, 926, 861 and 991
in Connecticut (NY is a bit below that).
There were at least a few codes that I suspect are never billed anymore.
Take for example L5060 (Ankle, Symes, metal frame, molded leather socket,
articulated ankle/foot or L 5639 Addition to lower extremity, BK wood
socket). Who has made such a device in the last 30 years?
Section 1834(a)(15) (see pg 6) of the Act authorizes the Secretary to
develop and periodically update a list of DMEPOS that the Sec'y determines,
on the basis of prior payment experience, are frequently subject to
unnecessary utilization and to develop a PA process for these items.
So it wouldn't be a wild conclusion to suggest that there was no
selectivity to their choice of codes to require (in the future as proposed)
prior approval. The case could as well be made that there is probably no
substantial evidence that ALL these codes are subject to over utilization.
So the pretext of trying to stop fraud and abuse will more likely result in
the delay and then the denial of coverage and service to those in need.
We still don't know who will make the decisions or how they will be made.
Who will meet the prior authorization requirements and the criteria for
such decision making. Will there be differing standards for pre and post
review audits?
Orthotics can't be far behind. ( A personal opinion)
Herb Shalant, C.P.O.
President NYSAAOP
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From: Herb Shalant [mailto:<Email Address Redacted>]
Sent: Friday, July 18, 2014 11:16 AM
To: 'Paul E Prusakowski'
Cc: O & P List Serve ( <Email Address Redacted> )
Subject: RE: [OANDP-L] NAAOP position on prior authorization
Paul and Fellow List-Serve readers,
I went through the entire list of Lower Extremity Prosthetic codes (89 in
total as proposed ) and found that with the exception of 3 codes (L5859, L
5961, and L 5969 which are advanced knee, hip and ankle components with
recent inclusion into the code set) they included every prosthetic code
that exists that reimburses over $1000 in Region A where I practice. They
included 5 codes that reimburse under $1000 in my Region (L 5606, L5718,
L5722, L5816, L5848 ). These codes reimburse at $998, 987, 926, 861 and 991
in Connecticut (NY is a bit below that).
There were at least a few codes that I suspect are never billed anymore.
Take for example L5060 (Ankle, Symes, metal frame, molded leather socket,
articulated ankle/foot or L 5639 Addition to lower extremity, BK wood
socket). Who has made such a device in the last 30 years?
Section 1834(a)(15) (see pg 6) of the Act authorizes the Secretary to
develop and periodically update a list of DMEPOS that the Sec'y determines,
on the basis of prior payment experience, are frequently subject to
unnecessary utilization and to develop a PA process for these items.
So it wouldn't be a wild conclusion to suggest that there was no
selectivity to their choice of codes to require (in the future as proposed)
prior approval. The case could as well be made that there is probably no
substantial evidence that ALL these codes are subject to over utilization.
So the pretext of trying to stop fraud and abuse will more likely result in
the delay and then the denial of coverage and service to those in need.
We still don't know who will make the decisions or how they will be made.
Who will meet the prior authorization requirements and the criteria for
such decision making. Will there be differing standards for pre and post
review audits?
Orthotics can't be far behind. ( A personal opinion)
Herb Shalant, C.P.O.
President NYSAAOP
---
This email is free from viruses and malware because avast! Antivirus protection is active.
<URL Redacted>
********************
To unsubscribe, send a message to: <Email Address Redacted> with
the words UNSUB OANDP-L in the body of the
message.
If you have a problem unsubscribing,or have other
questions, send e-mail to the moderator
Paul E. Prusakowski,CPO at <Email Address Redacted>
OANDP-L is a forum for the discussion of topics
related to Orthotics and Prosthetics.
Public commercial postings are forbidden. Responses to inquiries
should not be sent to the entire oandp-l list. Professional credentials
or affiliations should be used in all communications.
Citation
Herb Shalant, “prior authorization for prosthetics,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/236565.
