Moving the HME Industry Forward

Legislative/Advocacy

Sub-Regulatory Guidance to Play Major Role in Shaping Prior Authorization

January 11, 2016

WASHINGTON, DC – On Dec 29, 2015, CMS published the final rule to Medicare Program; Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies. This comes a year and a half after the proposed rule which came out on May 28, 2014. Originally CMS proposed that the timeframe for a response to a prior authorization request will be made within 10 days or 2 days for expedited requests. In July 2014, AAHomecare commented that prior authorization decisions must be completed within 24 hours or 2 hours for expedited requests in order to meet patient needs.  

AAHomecare was pleased to learn that CMS will not be finalizing the proposed time frames. CMS also announced the DMEPOS items and the start date of the prior authorization program have also not been finalized but all of this information will be provided in the sub-regulatory guideline which will be published sometime in the foreseeable future.

The DMEPOS items that will be eligible for prior authorization are based on data that showed a high rate of fraud or over utilization and payment threshold of an average purchase fee of at least $1,000 or an average monthly rental fee schedule of at least $100. The item list that was presented in the original proposal was changed to include an addition of oxygen concentrator (E1390) and removal of the following items:

• Custom shaped protective cover, above knee (L5705)
• Custom shaped protective cover, knee disarticulation (L5706)
• Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control (L5718)
• Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control (L5722)
• Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock (L5816)

However, not all items on the 135 item list will be subject to having a prior authorization requirement. CMS will determine which items out of the list will be required to have a prior authorization and will publish it in the sub-regulatory guideline.

AAHomecare is currently analyzing the regulation and will monitor the release of the sub-regulatory guideline.

HME Legislative Priorities Remain in Focus as Congress Returns to Town
WASHINGTON, DC – The House of Representatives returned to work last week, and the Senate convenes again starting today. Even though 2016 is an election year, the House and Senate are scheduled to be in session throughout the year (see schedule here); giving us plenty of plenty of opportunity to continue to advocate and help build co-sponsorship for legislation covering competitive bidding rural relief (H.R. 4185 and S. 2312) as well as preventing efforts to apply bidding derived pricing for complex rehab accessories  (H.R. 3229 and S. 2196).

In addition, AAHomecare expects legislation to address a proposed 35% cut to ventilator services (E0464 and E0463) to be introduced in this session; see this December 2015 letter to CMS from 22 members of Congress for additional perspective on the issue. AAHomecare staff and other industry stakeholders have started meeting with champions on Capitol Hill to strategize on moving these initiatives forward in 2016.

If you are interested in planning a site visit or in district meeting with your legislators, Congress will be in recess during these periods (breaks of 3 days or more) in the first half of 2016:

• Jan.14-22 (House)
• Feb. 15-19 (House & Senate)
• Mar. 4-11 (House)
• Mar. 21-23 (Senate)
• Mar. 24-Apr. 1 (House & Senate)
• Apr. 4-11 (House)
• May 2-6 (House & Senate)
• May 30-June 3 (House & Senate)
• June 27-July 1 (House)
• July 1-6 (Senate)