Preventing prior-authorization denials for custom orthotics

Preventing prior-authorization denials for custom orthotics

Custom-orthotics are frequently denied by insurers and these can be costly denials. Navigating Prior Authorization Denials for Orthotics and Prosthetics Prior authorization requirements for certain orthotics and prosthetics have been implemented by the Centers for Medicare & Medicaid Services (CMS) to ensure appropriate utilization and reduce unnecessary spending. However, denials can still occur even with prior authorization in place. Here are some key points to keep in mind when dealing with prior authorization related denials for orthotics and prosthetics:

1. Understand the Prior Authorization Process

• Prior authorization is required for select orthotics and prosthetics HCPCS codes
• Suppliers must submit documentation supporting medical necessity to the appropriate DME MAC jurisdiction
• Initial review decisions are made within 5-10 business days, with expedited reviews in 2 business days

2. Common Reasons for Non-Affirmative Decisions

• Insufficient documentation to support medical necessity
• Missing or incomplete required elements like the standard written order
• Incorrect HCPCS coding or modifiers
• Lack of face-to-face encounter documentation

3. Appealing a Non-Affirmative Decision

• Suppliers can submit a redetermination request to the DME MAC within 120 days of the initial decision
• Provide additional supporting documentation to address the reasons for non-affirmation
• Ensure all required elements are included and correct

4. Bypassing Prior Authorization in Urgent Situations

• Modifiers ST, KV, J4, or J5 can be used to bypass prior authorization when the item is needed urgently
• Claims billed with these modifiers are subject to prepayment review
• Strict criteria must be met, such as furnishing the item as part of a physician office visit or therapy session

5. Staying Compliant and Minimizing Denials

• Thoroughly document medical necessity in the patient's medical record
• Ensure all required elements are included in the prior authorization submission
• Utilize the DME MAC's resources and guidance on the prior authorization process
• Consider partnering with a prior authorization service provider to optimize submissions

By understanding the prior authorization process, common denial reasons, and strategies for appealing or bypassing denials, suppliers can navigate the challenges and minimize disruptions to patient care. Staying compliant and proactive in the prior authorization process is key to minimizing denials and ensuring timely reimbursement for orthotics and prosthetics.