AAFP Criticizes Proposed Rule on Prior Authorization Process

AAFP Criticizes Proposed Rule on Prior Authorization Process

CMS proposed rule on prior authorization for certain durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) has infuriated many family practice physicians. American Academy of Family Practitioners (AAFP) Board Chair Jeff Cain, M.D., of Denver, has asked CMS to address certain discrepancies in the proposal and to "accurately account for the burden on physicians" before adopting a final rule.

In a letter to CMS, Cain took issue with CMS' definition of "unnecessary utilization" — described as furnishing items that do not comply with one or more of Medicare's coverage, coding and payment rules — and noted that Medicare's view of "necessary" could be very different from that of physicians and patients. He urged CMS to allow evidence-based medicine to "dictate the measure of 'necessity' in medicine."

AAFP is also concerned with the language CMS has proposed regarding provisional affirmations that later could be denied based on technical requirements that are evaluated after a claim was submitted for formal processing. "This proposal undermines the original intent of a prior authorization," said Cain. "What good is 'prior authorization' if the supplier and the beneficiary cannot depend upon it?"

Read Cain's letter to CMS here.