CMS: M.D.s Requesting Prior Auth for Hospitals Could 'Bridge Gap'

As it carries out the new prior authorization process[1] for five hospital outpatient procedures, with two more in the wings and presumably more to come, CMS has opened its eyes to the challenges for hospitals, a program integrity official said Oct. 19 at CMS’s virtual Provider Compliance Focus Group.

For one thing, while physicians request prior authorization for outpatient procedures in the commercial insurance and Medicare Advantage world, the task falls to hospitals in the Medicare fee-for-service version, which started July 1, said Amy Cinquegrani, director of payment methods and strategies in CMS’s Center for Program Integrity. CMS’s hands were tied when it designed the program “because of the way the statute was written that authorizes CMS to develop programs to control unnecessary expenditures,” she said. “It’s very specific that the hospital outpatient department has to request prior authorization.”

In light of the constraints, CMS encourages physicians and hospital outpatient departments to “work together,” with physicians requesting prior authorization on behalf of the hospital. A lot of pieces must fall into place. Physicians have to put hospital data on the forms, including the hospital’s National Provider Identifier (NPI) and provider transaction access number, “to make sure the outpatient department gets the unique tracking number to put on the claim to make sure it can be approved for payment,” she explained. “We are hoping this can continue to bridge that gap between the practitioner and the facility.”

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