Prior Authorization Process for Non-Emergent Hyperbaric Oxygen Therapy
OVERVIEW
The Centers for Medicare & Medicaid Services (CMS) will begin implementing a prior authorization demonstration program for non-emergent hyperbaric oxygen therapy in Illinois, Michigan, and New Jersey. CMS will test whether prior authorization helps reduce expenditures, while maintaining or improving quality of care. CMS believes using a prior authorization process will help ensure services are provided in compliance with applicable Medicare coverage, coding, and payment rules before services are rendered and claims are paid.
BACKGROUND
In 2012, CMS launched a prior authorization process for certain power mobility devices in seven demonstration states (California, Florida, Illinois, Michigan, New York, North Carolina, and Texas). Since implementing this demonstration, CMS has observed a decrease in expenditures for power mobility devices. CMS will leverage this success by creating a prior authorization process for certain non-emergent services under Medicare. CMS seeks to use this process to address growing concerns about beneficiaries receiving non-medically necessary about non-emergent hyperbaric oxygen therapy. Illinois, Michigan, and New Jersey were selected for the initial implementation of this process because of their high utilization and improper payment rates for these services.
Under Section 1115A of the Social Security Act, the Secretary has authority to test innovative payment and service delivery models to reduce program expenditures, while preserving or enhancing the quality of care furnished to individuals under such titles.
Prior authorization will not create new clinical documentation requirements. Instead, it will require the same information necessary to support Medicare payment, just earlier in the process. Prior authorization allows providers and suppliers to address issues with claims prior to rending services and to avoid an appeal process. This will help ensure that all relevant coverage, coding, and clinical documentation requirements are met before the service is rendered to the beneficiary and before the claim is submitted for payment.
PRIOR AUTHORIZATION PROCESS
The model will establish a prior authorization process for hyperbaric oxygen therapy services. This process will allow all relevant documentation to be submitted for review prior to rendering services. CMS or its contractors will review the request and provide an affirmative or non-affirmative decision. A claim submitted with an affirmative prior authorization will be paid so long as all other requirements are met. A claim submitted with a non-affirmative decision will be denied. Unlimited resubmissions are allowed. If a provider or supplier chooses to forego prior authorization and submits a claim without a prior authorization decision, that claim shall undergo pre-payment review.
CMS Medicare Review Contractors will review prior authorization requests to ensure requests are consistent with all existing applicable regulations, National Coverage Determination and Local Coverage Determination requirements, and other CMS policies. No new documentation requirements were developed. Decisions on initial requests will be postmarked within 10 business days and subsequent requests will be processed within 20 business days. A provisional affirmative prior authorization decision may affirm up to 36 courses of treatment in a year.
To address circumstances where applying the standard timeframe for making a prior authorization decision could seriously jeopardize the life or health of the beneficiary, CMS included an expedited review process. The request for an expedited review must include rationale supporting the expedited review request. Such a request must include documentation that shows that applying the standard timeframe for making a decision could seriously jeopardize the life or health of the beneficiary. In these situations, the review entity will make reasonable efforts to communicate the decision within 2 business days of receipt of all applicable Medicare required documentation.
The six conditions available for prior authorization are:
- preparation and preservation of compromised skin grafts (not for primary management of wounds);
- chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management;
- osteoradionecrosis as an adjunct to conventional treatment;
- soft tissue radionecrosis as an adjunct to conventional treatment;
- actinomycrosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment; and,
- diabetic wounds of the lower extremities in patients who meet the following three criteria:
- patient has Type I or Type II diabetes and - has a lower extremity wound that is due to diabetes;
- patient has a wound classified as Wagner grade III or higher; and
- patient has failed an adequate course of wound therapy as defined in the National Coverage Determination.
Additional details on the prior authorization process for non-emergent hyperbaric oxygen therapy can be found on the CMS website at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Overview.html. Details will be discussed on an upcoming Open Door Forum Call which will be announced on the CMS website. Specific questions should be sent to MedicareMedicalReview@cms.hhs.gov.
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