100 Percent Prior Authorization Approvals Continue

Date Published: November 28 2012 continues its record of 100 percent Prior Authorization approvals since its Sept. 1 launch. was designed by physicians in an effort to provide healthcare practitioners with an easy and accurate solution to Medicare’s medical equipment documentation requirements.   

“Physicians who have utilized to help facilitate their face-to-face evaluations have had 100 percent approval for Prior Authorization,” said Jamie Loper, co-founder. “It’s not magic. The program simply acts as an intermediary between the physician and the Medicare coverage criteria, to determine what equipment, if any, the patient qualifies for.”’s algorithmic program compares the physician’s answers to questions regarding the patient’s diagnosis, history and face-to-face exam to Medicare’s coverage criteria. completely eliminates any questions the physician and the DME provider may have as to what equipment the patient qualifies for.

“ is a win-win for DME companies, physicians and insurance companies such as Medicare because it lets the physician and patient know if they are going to qualify for any equipment. If the patient does qualify, it ensures that the paperwork is correct,” Loper said. “Compliance and efficiency can go hand in hand.”

When utilizing’s algorithmic program, a physician can complete a face-to-face evaluation in about 20 minutes. When the evaluation is complete, the program produces the detailed written order (7 element order for a powered mobility device) and the complete face-to-face evaluation in a narrative format.

Constant audits and the Prior Authorization Demonstration Project have made it critical for DME companies to receive the correct paperwork from physicians prescribing assistive devices.

Medicare and Medicare contractors reporting the outcomes of the Prior Authorization Demonstration Project, Pre-Payment, Post-payment and ZPIC audits consistently show denial rates greater than 50 percent, and have been as high as 90 percent.

“Our research has shown that many, if not the majority, of the denied claims in the Prior Authorization Project were a result of incomplete physician documentation,” said Katherine Sims, Director of Marketing and Communications for

“The denials were not necessarily because the patient did not have the medical necessity for the equipment, but because the physician did not address all of the Medicare coverage criteria.”

Some in the DME industry have regarded electronic templates to be the answer to the high denials.

“While an electronic template would guide the physician as to what questions needed to be addressed, it does not ensure accurate documentation,” Sims said.

“ incorporates the concept of an electronic template for medical justification and takes that idea a quantum leap forward.”

"I love the model -- it solves one of our toughest issues in providing power wheelchairs," Chris Smythe, Tycon Medical Systems Inc., Norfolk VA, said.

Physicians who have traditionally balked at introducing additional software or methodologies to their practice are embracing

Medicare’s Prior Authorization Project has made the physician more accountable for providing complete and accurate medical documentation. When the beneficiary receives a denial from Medicare stating that the documentation the physician submitted was incomplete, they are holding the physician accountable.

When the physician is utilizing for the face-to-face evaluation, the program will inform him/her what equipment the patient qualifies for. If the patient doesn’t qualify for power mobility, the program will recommend other equipment based on the answers provided during the evaluation. Physicians are finding the program is improving their patient relationships because they are able to take a consultative approach when completing the evaluation.  Discussing why the patient doesn’t qualify is much easier with the information readily available. 

Physicians are also finding that saves them a tremendous amount of time and money. DME providers requesting further documentation have traditionally required a significant time commitment from the physician’s office staff. With the Prior Authorization Project, physicians are finding that with a denial of incomplete documentation, they must now schedule the patient for an additional face-to-face evaluation that they can’t bill for.

“ is the perfect solution to time management and accurate documentation,” said James Smith, M.D., Internal Medicine Physician. “During a face-to-face patient assessment, there are times when it’s unclear when further documentation is needed. makes it clear when additional documentation is required.”

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" is the perfect solution to time management and accurate documentation," James Smith, M.D.