Julia Kuzel

Public Service Announcement: Medicare DME Pre-Authorizations - you ready?

On February 29, 2016, the final rule became effective for the pre-authorization for durable medical equipment through the Centers for Medicare & Medicaid Services (CMS). The implementation date, itself, has not been set, but can kick in at any time with only a 60-day notification. CMS published a master list, which includes Durable Medical Equipment (DME) that cost over $1000, or have a rental fee schedule over $100. The list will be updated annually. Confusingly, the master list is about equipment that could potentially require pre-authorization. The pre-authorization list will be comprised of some of the items off the master list, but not all.

Pre-authorizations will need to be performed before patients receive DMEs. Generally a decision is guaranteed within 10 days for normal cases, however for medical emergencies, the decision can be expedited but clinical documentation must be provided. This documentation must demonstrate that a delay will put the patient at a severe health risk.

How does this affect health care workers?

This rule was put in place to help protect the Medicare beneficiaries (aka patients) from getting stuck with medical bills for DMEs not reimbursed by Medicare. While the rule is intended to benefit patients, they may not view it this way. Part of the reason patients have high satisfaction levels with Medicare is because Medicare generally does not have the cost-saving barriers put in place by private insurance carriers. Patients are accustomed to receiving treatment without referrals or Pre-Authorizations. Patients may not be aware of the upcoming changes, so be ready for some push-back, confusion, and frustration from delays. As a first line for patients, healthcare workers will receive the brunt of anger and frustration targeted towards the inefficient healthcare system.

Now healthcare workers will have to keep up with another list of requirements. This list will require constant monitoring because DMEs can be added or removed from the list without much notification. Clinical staff will also need to add another workflow to their daily responsibilities: beforehand, staff would know they did not need to do anything for Medicare patients, now they have to check on everything.

How can problems from the new rules be avoided?

One of the best ways to alleviate this new burdens is relatively simple: good communication. A best practice is to assume patients do not know any details of their health plans. Coverages can be extremely confusing and constant change will not help. Staff should take it upon themselves to discuss with patients the expected delays, which could take up to 10 business days. Part of this will mean patients should be notified as soon as there is a change to the status of the pre-authorization, but it may come by mail and is not immediate.

Healthcare providers should also keep close track of any changes by CMS. When pre-authorization becomes a requirement, staff should maintain an organized documentation system of the steps to submit a Pre-Authorization, the status of the Pre-Authorization, and ways to track a completed Pre-Authorization. Save copies of the cover sheet on your computer, with all office information pre-filled out. This will save time and means staff will only need to add patient specific information.

Next Health Choice can help

Next Health Choice specializes in Pre-Authorizations. With an online system that stays on top of requirement and law changes, clinical offices, service providers, and DME vendors can rest assured knowing that Next Health Choice monitors DME requirement changes and stays up to date so administrative staff can get back to helping patients. With consistent communication, Next Health Choice helps staff and patients stay well informed.

More patient time, less office work

Get in touch with Next Health Choice today to learn more.


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