CMS issues final rule that includes home oxygen and home sleep therapy devices on a list of items to be considered for prior authorization
January 7, 2016, Washington, DC – The Council for Quality Respiratory Care (CQRC) applauds the Centers for Medicare and Medicaid Services (CMS) in taking a critical first step toward bringing predictability and consistency to the Medicare audit process. Just before the new year, CMS announced that it has included oxygen concentrators and CPAP devices on the Master List of items that the Agency will consider for prior authorization.
The CQRC strongly supports eliminating fraud and abuse in the Medicare program. These efforts should be rational, balanced, and targeted to ensure that scarce Medicare funds are directed at activities that should be curtailed. Implementing a prior authorization process that establishes clear documentation requirements and provides a determination of medical necessity for home respiratory therapies upfront would provide the needed balance.
More than 1 million Medicare beneficiaries rely upon home respiratory therapies to treat Chronic Obstructive Pulmonary Disease (COPD) and Obstructive Sleep Apnea. Home oxygen and sleep therapies allow patients to remain at home with their families. Home respiratory therapy suppliers provide patient-‐centered services to reduce hospitalizations and keep patients in their homes, reducing overall health care spending.
The current auditing activity places beneficiary access to home respiratory therapy at risk and does not reflect a balanced approach. During the past several years, CQRC members have experienced a ten-fold increase in auditing activity. While the initial denial rate is substantial, the objective Administrative Law Judges overturn the vast majority of these denials in favor of the suppliers.
“Unfortunately, the current audit process makes it extremely difficult and time consuming for legitimate providers to be paid,” said Dan Starck, CQRC Chairman and CEO of Apria Healthcare. “The current process is highly inefficient, costly, inconsistent, and burdensome for suppliers, beneficiaries, and the federal government. As reimbursement rates are reduced, efficiencies in the process must be found, all the while, protecting the integrity of the payment process and eliminating fraud and abuse.
We believe that the proper implementation of Prior Authorization builds the right foundation.”
CQRC supports prior authorization because it will establish whether all of the documentation requirements have been met before equipment is delivered. “We know first-‐hand from working with managed care plans and many State Medicaid Agencies that prior authorization will work for home oxygen and sleep therapy,” Starck added. “It will be important to get the details of the process right and we look forward to working with CMS on the design and implementation of prior authorization to ensure its success.”
Who We Are
The CQRC is a coalition of the nation’s eight leading home respiratory therapy providers and equipment manufactures. CQRC members currently provide home respiratory therapy to more than 600,000 program beneficiaries who rely on treatment at home to maintain their independence and enhance their quality of life. Together they employ more than 35,000 people across the United States.
Millions of Americans are living with COPD and Obstructive Sleep Apnea, experiencing acute respiratory failure, or living with neuromuscular diseases. These individuals rely upon home respiratory therapies to remain at home. Learn more about home respiratory therapies and how they can help.
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