Prior authorization for Durable Medical Equipment remains a sore point for DME practices and businesses. Frequent authorization denials and subsequent delivery delays result in burnout and frustration. There are limited automation options and for an industry whose success hinges on timely approval of PA requests it is essential to have an effective prior authorization strategy.
The prior authorization request must include evidence that the medical item complies with all insurance coverage, coding and reimbursement rules. Relevant supplier provided documentation must be furnished. The request must comply with Local Coverage Determinations (LCD).
Prior authorization for DMEPOS is a long winded process with multiple stakeholders. It is important that key players in the ecosystem are compliant with prior authorization programs for their particular jurisdiction.
PA denials occur if the patient’s certificate of Medical Necessity (CMN) history indicates that the patient had received a medical equipment that is similar to the DMEPOS item being billed.
CMS requires mandatory prior authorization for a list of PMD codes. The complete list of medical codes and descriptions can be found here.