Home Medical Equipment (HME) can be vital to patient survival.
In the forefront in healthcare, Prior Authorization (PA) needs a considerable amount of attention to streamline efficiencies for prescribing HME. A staggering 91% of all care delays occur because of issues with the PA process, according to an AMA conducted survey.
Prior Authorization requirements are nothing new. Its predecessor, utilization review (UR) dates back to the 1960s following new Medicare and Medicaid legislation passing.
The evolution of technology and electronic medical records (EMR) presents opportunities of visibility into healthcare records not previously available. Because of these advancements, insurance companies have upgraded their PA practices, and these requirements often delay and impact efficient healthcare practices.
The top 3 HME Prior Authorization issues causing headaches throughout the healthcare industry are explained below.
#1: Not all Payor Prior Authorization Requirements are the Same
Many entities believe that physicians prescribing HME know all the required questions and criteria to be documented, justifying the prescription of a medical device beyond a qualifying diagnosis.
Though physicians are very intelligent, they lean heavily on the services of an HME vendor to educate the applicable rules and requirements needed to support medical necessity of the qualifying diagnosis.
Rules and requirements can vary significantly from payor to payor, resulting in the HME vendor becoming a Subject Matter Expert (SME) in documenting for specific devices. Correct documentation of the physician and patient encounter is vital to an HME business. HME vendors cannot submit to a given payor for reimbursement without documentation of medical necessity.
Unlike documentation required for a prescription of a pharmaceutical drug, the documentation for HME is much more detailed and cumbersome. Placing responsibility on a physician to be the SME regarding medical equipment qualifications is unrealistic, and it requires the physician to focus more on completing paperwork than actually seeing and treating more patients.
This also delays the dispensing of the script to the HME vendor, which ultimately delays service and treatment to the patient.
#2: Prior Authorization does not Ensure Coverage or Reimbursement
Even though a request for PA is approved, it does not guarantee reimbursement to the HME or coverage to the patient. The HME must still go back to the physician and get additional supporting documentation completed to meet guidelines in case of an audit by any given payor.
The HME vendor is financially impacted by the discretion of coverage. They are the ones that must ensure complete and accurate documentation is on file prior to providing products or services to the patient. Prior authorization does not guarantee the HME vendor will be reimbursed fully for their service. Prior authorization also does not guarantee the patient won’t have to pay out of pocket for the product or service. The patient could have full or partial financial responsibility.
As you can see, PA just slows down the process and time elapsed between prescribing and fulfilling a patient’s need for HME products or services.
#3: Not all HME is Created Equal
While PA has good intent in minimizing fraud and abuse, some HME is more important and vital to patient survival than others.
For example, oxygen is an HME prescription that directly impacts a patient’s ability to breathe, and ultimately live, whereas a wheelchair can improve mobility, and ultimately the quality of life, of a patient. While both oxygen and wheelchairs fall into the HME family, the do not share the same weight when it comes to keeping a patient alive.
Enforced PA requirements cannot be congruent to all categories of HME. Survival items as opposed to convenience or aiding items should not have the same required PA workflow. While PA is meant to minimize cost, making a patient stay additional days in the hospital while waiting for PA for oxygen treatment ultimately ends in higher costs.
Revamping the PA workflow for oxygen could save insurance companies money by allowing patients to discharge from the hospital faster and receiving the same treatments from the comfort of their home.
Standardized requirements that Support Interoperability
In this vastly evolving world of technology, it’s imperative to create standardization of requirements to support interoperability and streamlined workflows to reduce healthcare spend. The key to success of a PA workflow is to define the standard criteria based on the qualifying diagnosis for the designated HME while eliminating any required documentation that generates duplicated efforts.
Standardization clears the path to ensure seamless interoperability between entities. The technology exists to do it. The industry now needs to define the rules.