Following are a breakdown of those services and a review of strategies for preparing for implementation.
Services on the list of outpatient department services requiring prior authorization typically are those that CMS has identified as being performed mainly for cosmetic purposes and that therefore might pose a potential risk for incorrect payment based on medical necessity concerns. The five service categories1 are:
To ready themselves for implementation of the new prior authorization rule, healthcare leaders should:
Thoroughly understanding this and the other OPPS rules that went into effect in January – and related implications for their organizations – are musts for healthcare leaders. For additional guidance, leaders should seek assistance from third-party specialists.
1 “Final Rule: CMS-1717-FC: Prior Authorization Process and Requirements for Certain Hospital Outpatient Department (OPD) Services; Table 65: Final List of Outpatient Services That Require Prior Authorization,” Centers for Medicare & Medicaid Services, Federal Register, Vol. 84, No. 218, Nov. 12, 2019, https://www.cms.gov/files/document/cpi-opps-pa-list-services.pdf
2 “CY 2020 OPPS/ASC Final Rule Executive Summary,” Healthcare Financial Management Association, Jan. 8, 2020, https://www.hfma.org/industry-initiatives/regulatory-and-accounting-resources/fact-sheets/cy2020-opps-asc-final-rule-executive-summary.html; "Medicare Program: Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Revisions of Organ Procurement Organizations Conditions of Coverage; Prior Authorization Process and Requirements for Certain Covered Outpatient Department Services; Potential Changes to the Laboratory Date of Service Policy; Changes to Grandfathered Children’s Hospitals-Within-Hospitals; Notice of Closure of Two Teaching Hospitals and Opportunity to Apply for Available Slots," Centers for Medicare & Medicaid Services, Federal Register, Vol. 84, No. 218, Nov. 12, 2019, https://www.federalregister.gov/documents/2019/11/12/2019-24138/medicare-program-changes-to-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center; “AMA Releases 2020 CPT Code Set,” American Medical Association, Sept. 4, 2019, https://www.ama-assn.org/press-center/press-releases/ama-releases-2020-cpt-code-set