CMS Issues Final Rule for DMEPOS
- By BSTQ Staff
The Centers for Medicare and Medicaid Services (CMS) has issued a final rule that mandates prior authorization for some durable medical equipment prosthetics, orthotics and supplies (DMEPOS). Under the rule, documentation to meet authorization for DMEPOS is needed earlier in the process to furnish the items, 80 percent of which the cost will be covered if a physician deems the item necessary. The rule allows CMS to move away from a “pay and chase” model under which CMS makes payments on claims and then tries to recoup them after it identifies claims are improper. A 2011 report from the Health and Human Services Office of Inspector General found that 61 percent of power wheelchairs provided in the first six months of 2007 were medically unnecessary or lacked sufficient documentation to determine medical necessity.
The rule will include a master list of 135 products that are frequently deemed medically unnecessary that will be updated annually and for which a prior authorization process will be developed. Because the items on the master list don’t automatically require prior authorization, CMS will publish a subset of that list in the Federal Register with 60 days notice for the products that do require prior authorization.
