Commentary: The Reality Behind the Prior Authorization Opt-Out

Not everything that looks like a gift turns out to be one, just as not every shortcut saves time overall.

A current example: The Centers for Medicare & Medicaid Services (CMS) will be offering to exclude a select group of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) providers from prior authorization requirements, according to a Jan. 13 announcement from CGS Administrators, the Jurisdictions B and C DME MAC.

“If the supplier’s [prior authorization] approval rate is 90% or higher, they will have an option each year to be exempt from submitting prior authorizations for that year,” CGS said. “To determine supplier eligibility for continued exemption, the DME MACs will conduct an annual post-payment medical review sample to ensure compliance. From this claim sample, suppliers must again meet a claim approval rate of 90% or greater to continue their exemption.”

Read the full article from Mobility Management here.