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Legislative Alert: Prior Authorization Bill Reintroduced in the U.S. House

Legislative Alert: Prior Authorization Bill Reintroduced in the U.S. House
Rep. Marsha Blackburn (R-Tenn.)

Rep. Marsha Blackburn (R-Tenn.) has reintroduced a bill that would require a prior authorization for high dollar durable medical equipment. The bill title for H.R. 2445 will be the DMEPOS Access and Transparency Act of 2017, also referred to as the DATA Act of 2017. A similar version of prior authorization legislation was introduced in the last Congress by Blackburn.

At its core this legislation seeks to reduce the amount of burdensome audits against which providers continue to fight. The legislation states: A claim for an item of durable medical equipment, a prosthetic, an orthotic, or a supply that has received prior approval through the prior authorization process shall be exempt from subsequent pre- and post-payment audits and only subject to audits for systematic fraud and abuse. These pre-approved items could then only be subject to audits for fraud and abuse purposes. The intention of this to reduce the number of intrusive audits on DMEPOS suppliers.

An added provision to last year’s legislation outlines a more detailed process for home respiratory equipment, which would establish a requirement of medical necessity to be prescribed by a practitioner. The Department of Health and Human Services would establish a standard for the medical necessity evaluation requests for “physician and hospital referral agents and non-physician practitioners.”

VGM’s Vice President of VGM Government Relations, John Gallagher, said, “The prior authorization bill introduced by Congresswoman Blackburn is a strong step to reign in the excessive amount of audits that providers are buried in. Providers are losing crucial cash flow for years while they go through the appeals process, and this bill will play a big role in reducing those audits.”

Additionally, there would be a 72-hour window from the point the request was received for the prior authorization to be approved or denied. Within that provision is a special case scenario for hospital discharges and emergency reviews for certain items.

This legislation would create a more secure outlook in the future for independent medical suppliers. VGM will provide further analysis, calls for action, and updates as we follow this legislation.