CMS Moves Forward with Added Prior Authorization Requirements

CMS finalized new procedures that will be subject to prior authorization in 2023.

Earlier this year in the 2023 OPPS proposed rule, CMS brought forward a proposal to require prior authorization for an additional service category: facet joint injection procedures.

At the time, CMS said this would ensure Medicare beneficiaries receive medically necessary care while protecting the Medicare Trust Funds from unnecessary increases in volume by virtue of improper payments. This would happen without adding new documentation requirements for providers, CMS said.

Now, CMS finalized adding facet joint interventions to its hospital outpatient department prior authorization list in the recently released 2023 OPPS final rule, but with one change: In response to feedback, CMS scrapped its proposed March 1, 2023, effective date for this proposal. Instead, facet joint injection procedures will be subject to prior authorization starting July 1, 2023.

“Prior authorizations for joint injections will potentially affect providers not affected by the prior cosmetic or major back procedure requirements,” says Kimberly A. Hoy, JC, CPC, director of Medicare and compliance at HCPro. “CMS’ delay until July 1, 2023, in line with prior delays, rather than going forward March 1, 2023, will give providers needed time to prepare.”

CMS continues to cite the need to control unnecessary increases in volume as the deciding factor behind added prior authorizations each year.

CMS has seen a marked increase in the volume of facet joint injection procedures, so it’s not unreasonable for it to take steps to ensure they’re medically necessary, Ronald Hirsch, MD, FACP, CHCQM, CHRI, vice president of regulations and education at R1 RCM, told NAHRI.

Although prior authorization can be burdensome to the front-end revenue cycle, it can help avoid at least some denials on the back-end.

“From the provider side, it seems better to have assurance of payment prior to performing the procedure instead of incurring the costs of performing the procedure and then being denied payment afterwards,” Hirsch says.

While CMS agrees with that statement and says it will ensure that this measure will not burden patients or providers, many providers are not so sure. For example, as the American Medical Association previously found, prior authorizations of medical treatments and services has a negative impact on both patients and providers.

The American Medical Associations survey found that 93% of physicians reported that prior authorization led to delays of necessary care (14% always, 42% often, and 38% sometimes), and that 82% of physicians reported that the prior authorization process leads patients to abandon treatment (3% always, 24% often, 55% sometimes).

More than 1,000 practicing physicians participated in the American Medical Association survey, with 40% working as primary care physicians and 60% working as specialists.

As CMS is bound to add more procedures to the prior authorization list moving forward, time will tell of the effect on the front-end revenue cycle.