American Society of Plastic Surgeons
For Consumers

ASPS Joins Diverse Group Opposing Expanded Prior Auth for Hospital Outpatient Services

In comments submitted to CMS on their proposal to expand the prior authorization process for certain hospital out-patient services, ASPS has found new allies – from healthcare facilities to manufacturers and state medical societies - all of whom implored the Agency to ensure any processes established to address unnecessary increases in the volume of covered OPD services include:

  • Recognition that existing coverage criteria already requires detailed documentation of medical necessity
  • The implementation of a standardized prior authorization form, across all Medicare Administrative Contractors (MAC)
  • The ability to electronically submit prior authorization requests
  • Approval or denial of coverage determined and communicated no more than 48 hours after the receipt of the completed prior authorization form.
  • The prohibition of retrospective reviews and/or denials in all cases where a physician appropriately followed the prior authorization procedure and received approval to perform the surgery.
  • A transparent appeal and/or retroactive authorization process

ASPS has been made aware of multiple instances where several Medicare Administrative Contractors (MACs) are struggling to complete prior authorizations timely and/or have erroneously denied prior authorizations for medically necessary blepharoplasty. In addition to the comments submitted to CMS, ASPS will continue to advocate with MACs for timely feedback to ensure care is not delayed, or no longer offered by providers already over-burdened by the administrative complexities of the prior authorization process.