Blackburn Re-Introduces Prior Authorization Legislation

Bill aims to cut audit burden by requiring prior authorization for higher priced DME items.

Rep. Marsha Blackburn (R-Tenn.) has re-introduced legislation that would usher in prior authorization for claims on higher-priced HME items.

H.R. 2445, labeled the DMEPOS Access and Transparency Act (DATA) of 2017, is similar to prior authorization legislation that Blackburn had floated in the House last year. Both aim to reduce the volume of audits HME providers are enduring, by creating a prior authorization requirement.

Key provisions of the DATA Act:

  • A claim for a DME item that has been approved via the prior authorization process would be exempt from subsequent pre- and post-payment audits, and only subject to audits for systematic fraud and abuse.
  • A more detailed process for home respiratory equipment claims, which would require that a physician, hospital referral agent, or non-physician practitioners document medical necessity in accordance with standards that Department of Health and Human Services would establish.
  • A72-hour window beginning when the point the request was received for the prior authorization to be approved or denied. The bill makes accommodations for special cases such as hospital discharges and emergency reviews for certain items.

“This legislation will help stem the tide of Medicare audits that delay payments for providers and also tie up significant resources as providers answer and appeal them,” said Tom Ryan, president and CEO of the American Association for Homecare. “We applaud Congresswoman Blackburn’s longstanding efforts to help rein in excessive audits by establishing an effective prior authorization process that will both improve cash flow for providers and also allow them to concentrate more of their resources and energy on serving their patients.”

“The prior authorization bill introduced by Congresswoman Blackburn is a strong step to reign in the excessive amount of audits that providers are buried in,” said John Gallagher, Vice President of Government Relations for The VGM Group Inc. “Providers are losing crucial cash flow for years while they go through the appeals process, and this bill will play a big role in reducing those audits.”

The bill can be found on the Congress.gov site at http://bit.ly/2q320Zu, and a draft of the legislation is available at http://bit.ly/2qAu0Yj.

About the Author

David Kopf is the Editor of HME Business.

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