In an effort to reduce insurance fraud, waste and abuse, the Centers for Medicare and Medicaid Services will require pre-payment reviews for specified surgeries and pre-reimbursement authorizations for medical equipment in 11 states starting on Jan. 1, 2012.
These demonstration programs aim to cut down the amount of improper payments the federal insurers make by focusing on scenarios and states which see a high volume of fraud and error, the agency says.
In recovery audit prepayment reviews, inspectors will review claims for such surgeries as spinal fusions, joint replacements and pacemaker or defibrillator surgeries in order to prevent improperly paid claims before they're processed. This would provide an alternative to recovering overpayments after they're made. An appeals process would be set up for the potential resubmission of denied claims. Recovery audit prepayment reviews will affect providers in California, Florida, Illinois, Louisiana, Michigan, Missouri, New York, North Carolina, Ohio, Pennsylvania and Texas.
In the prior authorization for medical equipment program, claims for durable medical equipment such as wheelchairs, prosthetics, orthotics, CPAP machines and catheters will during the first 3 to 9 months undergo a prepayment review, then during the rest of the 3-year demonstration require private-insurer-style prior authorization to determine if Medicare or Medicaid beneficiaries' conditions warrant the equipment. Equipment authorization will apply to providers in California, Florida, Illinois, Michigan, New York, North Carolina and Texas.
David Bernard
