What’s Happening With Medicare? By O&P Insight

What’s Happening With Medicare?

By O&P Insight

With COVID-19 putting a halt to many major Medicare projects, suppliers and providers have been able to breathe a little over the past five months and focus on the health and well-being of their staff and patients. Even though COVID-19 is still a very real threat, our break from the reality of claim reviews and new programs is now over.

Prior Authorization is nothing new in the insurance industry, but it is still relatively new for Medicare. Medicare first launched their Prior Authorization program a few years ago with a handful of Power Mobility Device (PMD) codes. The success of the program has resulted in the inclusion of additional PMD codes as well as some Pressure Reducing Support Surface (PRSS) codes. COVID-19 delayed the expansion of the Prior Authorization program to Lower Limb Prosthetics (LLP) earlier this year, but Phase 1 is set to begin for Dates of Service (DOS) Sept. 1, 2020 for beneficiaries whose permanent address is California, Michigan, Texas, and Pennsylvania. Expansion to the remaining U.S. and U.S. territories will go into effect for DOS Dec. 1, 2020. This won’t apply to all LLP codes, just six specifically selected codes that happen to be microprocessor components that require the patient to be at or above a K3 functional level.

Suppliers have been on a “claim review hiatus” since the beginning of the COVID-19 pandemic, however, CMS has announced that post-payment claim reviews have restarted as of August 2020, some of which for claims with DOS prior to March 2020. Although it has not been officially announced, it is expected the pre-payment claim reviews, also known as the Targeted Probe and Educate (TPE) program, will restart in the near future as well.

It’s commonly said that the only consistent thing about Medicare is that it’s constantly changing. One can be actively prepared for such changes with a thorough and comprehensive Policies and Procedures Manual in place. If you have one already, when was it last reviewed/updated? O&P Insight has been actively working with our clients to develop customized policies and procedures manuals that will work to protect the business, including owners, staff, and patients. Having a current and thorough policies and procedures manual in place can help ease the “growing pains” of changes to payer policies and coverage for the patients you serve. Let us help you prepare for the future and curate a policies and procedures manual just for you.

Let O&P Insight help prepare your business for Prior Authorization, inevitable claim reviews or the ups and downs of owning a business. We offer assistance with process improvement/development, staffing infrastructure, training/education, revenue cycle management, and so much more. When it comes to Medicare, it’s always better to be proactive and prepared than reactive and blindsided. For more information about our team and services visit www.oandpinsight.com. For more information on Medicare and the programs mentioned in this article, visit www.cms.gov.