Texas physicians soon may encounter new Medicare prior authorization requirements for certain services that double as cosmetic procedures when provided at an ambulatory surgical center (ASC).
The Centers for Medicare & Medicaid Services (CMS) recently announced plans to test prior authorization for 40 services related to blepharoplasty, botulinum toxin injections, rhinoplasty, panniculectomy, and vein ablation in ASCs in 10 states, including Texas. The five-year demonstration project will begin Nov. 1, 2024, and run through October 2029.
“These targeted services can potentially be provided as cosmetic procedures, rather than medically necessary procedures, resulting in improper or fraudulent payments,” the federal agency said in a supporting statement.
The Texas Medical Association is a vocal opponent of prior authorization requirements, which add to physicians’ already considerable administrative burden. CMS acknowledges this burden in its statement, estimating the new requirements will collectively cost physician practices and other health care facilities 59,904 hours in clerical work and $2.23 million in associated costs each year.
As justification for the new prior authorization policy, CMS points to data showing a sharp uptick in the number of the targeted services performed on Medicare patients in ASCs between 2019 and 2021. The federal agency also suggests the increase stems from its own 2020 rule requiring prior authorization for the same services when performed in a hospital outpatient setting.
“There is considerable concern about unnecessary utilization of these services in the [hospital outpatient department] moving to the ASC as the [hospital outpatient department] prior authorization program continues and services are scrutinized,” according to the same statement.
Since the 2020 rule’s implementation, CMS says Medicare spending for the selected services in the hospital outpatient setting has dropped 28%, from $79.7 million to $57.3 million, and “[expects] similar results in the ASC setting."
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Emma Freer
Associate Editor
(512) 370-1383