As part of the Hospital Outpatient Prospective Payment (“OPPS”) Final Rule for 2020 published in the Federal Register on November 12, 2019, new regulatory requirements require prior authorization for certain Hospital Outpatient Department (“HOPD”) services as a condition of payment. Claims with dates of service July 1, 2020 related to or associated with these services will not be paid if the service requiring prior authorization is deemed not eligible for payment. Related services include, but are not limited to; anesthesia services, physician services, and facility services.
Background
The Centers for Medicare and Medicaid Services (“CMS”) experienced significant increases in utilization for certain covered HOPD services. Analysis demonstrated certain procedures that were likely to be cosmetic in nature and/or are directly related to cosmetic surgical procedures which are not covered by Medicare, could potentially be combined with or masquerading as therapeutic services. As a result of the analysis, CMS determined the following HOPD services will require prior authorization effective on or after July 1, 2020:
Blepharoplasty
Botulinum Toxin Injections
Panniculectomy
Rhinoplasty
Vein Ablation
The full list of affected CPT codes requiring prior authorization can be found at:
https://www.cms.gov/files/document/cpi-opps-pa-list-services.pdf
Prior authorization is a process by which a request for provisional affirmation of coverage is submitted for review before the service is rendered to a beneficiary and the claim is submitted for payment. Claims billed without first submitting a prior authorization request and receiving a provisional affirmation decision will be denied payment. Of note, this new process does not make any changes to current medical necessity requirements for the services rendered. The process includes the following steps.
1. Providers submit prior authorization requests to their respective Medicare Administrative Contractor (“MAC”).
The submission request can be made by fax, mail, MAC electronic portal, and Electronic Submission of Medical Documentation (esMD). Note, use of esMD for prior authorization requests for dates of service July 1, 2020 will only be available as of July 6, 2020. All other methods will be accepted starting June 17, 2020. There is no specific form to request prior authorization, but request must include:
Beneficiary, Physician/Practitioner, HOPD and Requester information;
Medical record documentation to support medical necessity of service(s);
Anticipated date of service;
HCPCS and applicable diagnosis codes;
The type of bill and units of service;
Whether the request is for an initial or subsequent review; and
If expedited review is requested, the reason for expedited need.
2. MAC Prior Authorization Decision
In its published Prior Authorization for Certain HOPD Services FAQ, CMS indicates the standard review timeframe is ten (10) business days from the date of prior authorization receipt, excluding federal holidays. An expedited review timeframe of two (2) business days can be requested should the standard timeframe jeopardize the health of the beneficiary. Expedited prior authorization requests must include justification to support why the standard timeframe would not be appropriate. The MAC will issue one of the three following written decisions:
Provisional Affirmation Decision – Preliminary finding that a future claim submitted to Medicare for the item or service likely meets Medicare’s coverage, coding, and payment requirements.
Non-Affirmation Decision – Preliminary finding that if a future claim is submitted for the item or service, it does not meet Medicare’s coverage, coding, and payment requirements.
Provisional Partial Affirmation – One or more service(s) on the request received a provisional affirmation decision and one or more service(s) received a non-affirmation decision.
The MAC decision notice will include the prior authorization unique tracking number (“UTN”). This UTN must be submitted on the claim in order to receive payment.
3. Resubmission Requests Following a Non-Affirmation Decision
MACs will provide a detailed reason along with the non-affirmation decision. Providers can ask for further information and/or clarification as well as provide additional documentation to address the non-affirmation decision in a resubmitted request, provided the service has not yet been rendered and submitted for payment. There is no limit to the number of resubmissions that can be performed.
Of note, non-affirmation decisions are not considered initial determinations and as such cannot be appealed. If a claim is submitted with a non-affirmation decision and is subsequently denied, this is considered an initial determination and is appealable.
4. Claims Denials and Post-Payment Review
MAC’s may deny a claim that has received a provisional affirmation based on the following:
Technical requirements that could only be evaluated after the claim has been submitted for formal processing; or
Information not available at the time of a prior authorization request.
Claims which have received a provisional affirmation decision will generally not be subject to additional review; however, CMS contractors may conduct targeted pre- and post-payment reviews if the provider shows evidence of potential fraud. In addition, the Comprehensive Error Rate Testing (“CERT”) contractor must review a random sample of claims for purposes of estimating the Medicare improper payment rate.
5. Future Provider Exemption
As part of the OPPS 2020 Final Rule, CMS has the authority to exempt a provider from the prior authorization process upon the provider’s demonstration of compliance with Medicare coverage, coding and payment rules in 42 CFR §419.83(c). A threshold of at least ninety percent (90%) prior authorization provisional affirmations during a semiannual assessment will allow this exemption.
As part of its FAQs on this topic, CMS identified exemptions will take up to ninety (90) days to effectuate and will remain in effect unless CMS elects to withdraw the exemption. Further, CMS anticipates exemptions for those providers who qualify will begin being granted sometime in 2021.
With the current focus on COVID-19, preparations for other regulatory changes may not be at the forefront. Proactive analysis and adjustment of applicable workflows along with education of appropriate providers and staff, will ensure a smooth transition for HOPD’s to meet the July 1, 2020 prior authorization requirements preventing future denials.