REIMBURSEMENT PAGE
By JOSEPH MCTERNAN
Adjusting to Medicare Changes How will prior authorization and competitive bidding impact O&P facilities?
Editor’s Note—Readers of Reimbursement Page are eligible to earn two CE credits. After reading this column, simply scan the QR code or use the link on page 17 to take the Reimbursement Page quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.
2020 E! QU IZ M EARN
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OU WILL BE HARD PRESSED to
find someone who is not happy to see 2020 in the rearview mirror. The COVID-19 public health emergency has impacted all aspects of our daily lives. Businesses have been forced to adjust their operations to be successful in an environment where personal interaction may no longer be an option. Telehealth has taken on a new level of importance—for O&P providers as well as their physician partners and other members of the rehab team. In addition to dealing with the continuing challenges associated with providing patient care during a global pandemic, O&P providers are faced with two new Medicare programs that will have a significant impact on their businesses in 2021: prior authorization and competitive bidding.
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JANUARY 2021 | O&P ALMANAC
Prior Authorization
Prior authorization is not a new concept, as it has been utilized by private payors for years. Medicare has been slowly introducing prior authorization into its claim processing program, but O&P was not part of the program until recently. Last year, Medicare implemented limited prior authorization for six lowerlimb prosthesis codes (L5856, L5857, L5858, L5973, L5980, and L5987) in four states (Pennsylvania, Michigan, Texas, and California) on September 1. The program was implemented nationwide for claims with dates of service on or after Dec. 1, 2020.
Detailed information about Medicare prior authorization for lower-limb prosthesis codes can be found on the AOPA website at www. aopanet.org/legislative-regulatory/ prior-authorization. Highlights of the program include the following: • Claims that receive an affirmative prior authorization decision will generally not be subject to additional audit or medical review but may be denied for technical reasons (e.g., no proof of delivery, delivery of services not included in the prior authorization request, etc.). • Effective for claims with dates of service on or after Jan. 1, 2021, products coded using one of the six codes subject to prior authorization must be code-verified by the pricing, data analysis, and coding contractor. • In general, Medicare will provide a prior authorization decision within 10 business days of receipt of the request. Expedited prior authorization requests will be processed in two business days. • There are no limits on prior authorization resubmissions, but each resubmission will result in additional processing time. • Prior authorization requests will be assigned a unique tracking number (UTN) that must be submitted with the claim. UTNs will be assigned for both affirmative and nonaffirmative prior authorization decisions.
