wheelchairs, oxygen, Administrative responsibilities for etc.) provider and Vision services (i.e. Less savings than stop” option “hard Prior Authorization eyewear, (cont.) frames, High cost imaging & $2.5M $0.9M Pros: May need to be See above low vision aids, Radiology Applies medical necessity criteria to modified with • orthoptic ensure appropriate delivery of Enhanced PCCM therapy/visual services & reduces overutilization model & for the training) Cons: managed care for Certain physician Increased administrative responsibility LTSS, as those • services (i.e. breast for providers companies will likely reconstruction & Increased State administrative establish their own • reduction, gastric responsibility PA bypass, mastopexy, transplant, etc.) PA currently under consideration for: Prosthetics Rate reductions Support 10% services reduction for adults - $2.4M $0.9M Pros: May impact savings See above with intellectual Medical Equipment disabilities: Immediate savings potential for 2010 & supplies Cons: initiatives. Nursing facilities: 7/1/10 The impact on providers increases Rehab & community over the years as costs rise & support services for reimbursement does not children with cognitive Providers may leave the market impairments/physical creating access issues for recipients
Prior Authorization (cont.) wheelchairs, oxygen, etc.) Vision services (i.e. eyewear, frames, low vision aids, orthoptic therapy/visual training) Certain physician services (i.e. breast reconstruction & reduction, gastric bypass, mastopexy, transplant, etc.) PA currently under consideration for: Prosthetics Administrative responsibilities for provider and Less savings than “hard stop” option High cost imaging & Radiology $2.5M $0.9M Pros: • Applies medical necessity criteria to ensure appropriate delivery of services & reduces overutilization Cons: • Increased administrative responsibility for providers • Increased State administrative responsibility May need to be modified with Enhanced PCCM model & for the managed care for LTSS, as those companies will likely establish their own PA See above Rate reductions Support services for adults with intellectual disabilities: 2010 Nursing facilities: 7/1/10 Rehab & community support services for children with cognitive impairments/physical 10% reduction - Medical Equipment & supplies $2.4M $0.9M Pros: Immediate savings Cons: The impact on providers increases over the years as costs rise & reimbursement does not Providers may leave the market creating access issues for recipients May impact savings potential for initiatives. See above
recommendation-report12-15-2012.docx