Today having an efficient DME billing transaction is almost next to impossible especially if you do not have the right experienced resources. This is because more than 52% of DME providers' today common concerns are - how to have the accurate documentation, how not to miss out on ROI and of course DME billing frauds. As all the DME including items like hospital beds, wheelchairs, walkers, and prosthetics, plays a crucial role in patient care; avoiding fraud is essential. And with recent years, instances of unnecessary utilization and incorrect billing have come to light, prompting CMS to take action. 

And so in an effort to curb rising Durable Medical Equipment fraud case and eliminate unnecessary utilization, the Centers for Medicare & Medicaid Services (CMS) has introduced a final rule on its pre-authorization program.  

Understanding the CMS Pre-Authorization Program: 

The CMS pre-authorization program for DMEPOS is designed to tackle fraudulent billing practices and ensure that DMEPOS items adhere to Medicare's coverage, medical coding, and payment rules. Here's what you need to know: 

1. Definition of "Unnecessary Utilization": CMS defines unnecessary utilization as the provision of items that do not comply with Medicare's rules and regulations regarding coverage, medical coding, and payment. 

2. Program Expansion: The program initially began in seven states in 2012 and expanded to 12 additional states in 2014. Furthermore, CMS has extended its three-year prior authorization program to power mobility devices. 

3. Program Goals: The pre-authorization program aims to achieve several important goals: 

• Ensure that all applicable rules are met before DMEPOS items are delivered. 
• Guarantee that beneficiaries receive medically necessary care while minimizing the risk of improper payments. 

• Prevent beneficiaries from bearing the cost of items that are not eligible for Medicare payment. 
• Master List of Products 

In fact, CMS has created a master list of 135 DMEPOS items that are frequently associated with unnecessary utilization. To make it onto this list, an item must meet specific criteria: 

The item should have been identified as potentially unnecessary in reports from entities like the Department of Health and Human Services' Office of the Inspector General (OIG), Government Accountability Office(GAO), and Comprehensive Error Rate Testing (CERT) Annual Medicare Fee-for-Service Improper Payment Report. 

The item must have an average purchase fee of $1,000 or greater or an average rental fee of $100 or greater as per the DMEPOS Fee Schedule. 

Final Rule Highlights 

The key highlights of the final rule for the CMS pre-authorization program thus include: 

• Documentation Submission: Healthcare providers or suppliers must submit evidence that the DMEPOS item complies with Medicare's rules before delivering the item and submitting a claim. 
• Medical Review: CMS or its review contractors will conduct a medical review upon receiving all necessary documentation. They will then decide whether to approve or reject the request. 
• Automatic Denial: Claims submitted without a provisional affirmation prior authorization decision will be automatically denied. 

• Resubmissions: Providers and suppliers are allowed unlimited resubmissions of prior authorization requests. 
• Economic Impact: The program is expected to cost approximately $1.3 million in the first year, $57 million in five years, and $212 million in ten years. 
• Timely Determinations: The review contractor aims to provide an initial prior authorization determination within 10 business days, while resubmission prior authorization determinations will take 20 business days. 

The CMS pre-authorization program for DMEPOS represents a significant step towards preventing fraud and ensuring that patients receive the necessary care they deserve. By requiring healthcare providers and suppliers to adhere to Medicare's rules and conduct thorough documentation before submitting claims, CMS is working to create a more transparent and accountable billing process. This initiative not only protects beneficiaries but also helps maintain the integrity of the healthcare system. 

Sunknowledge can Help You Avoid All Your DME Billing Fraud: 

Working in the industry for the last 15+ years, Sunknowledge has a good understanding of the present industry mandates, changing regulations and documentation needed to meet your DME billing requirements. With experienced billers and certified coders working constantly to improve your ROI, Sunknowledge expert further makes end meet but ensuring through checks and ensuring an accuracy rate of 99.9% and correct documentation and timely claims submission. Ensuring a seamless DME billing transaction, Sunknowledge today has a record of the highest productivity metrics in the industry.