CMS Expands Medicare Prior Authorization Pilot Project

On Thursday, CMS announced plans to expand a Medicare anti-fraud demonstration project that mandates prior authorization for certain medical devices and equipment before the items are delivered or claims for payment are submitted, The Hill reports (Viebeck, The Hill, 5/22).

Under the pilot program, seven states -- including California, Florida and Texas -- require prior authorization for items such as power scooters and wheelchairs (CMS release, 5/22). CMS said the requirement will expand to another 12 states, and the "master list" will include new devices and equipment used at home, such as orthotics and prosthetics.

Currently, Medicare typically determines whether to cover such devices after they already have been given to patients. If Medicare then denies the claim for the devices, patients must cover the cost. Under the new plan, beneficiaries will have to submit coverage, coding and clinical documents for certain medical devices prior to their delivery.

According to federal officials, the changes would save between $100 million and $740 million over the next decade. CMS also noted that the change would not delay care or require seniors to complete more paperwork.

The agency said it would rule on initial requests for devices within 10 business days and on all other requests within 20 business days. In addition, CMS outlined a process establishing a two-day review period for requests where the life or health of a patient could be jeopardized under the standard 10- to 20-day review period (The Hill, 5/22).