The American Association for Homecare (AAHomecare) and the ALS Association have expressed concern over “ongoing authorization challenges for medically necessary non-invasive ventilator (NIV) devices by Medicare Advantage (MA) payers,” as described in a June 14 announcement from AAHomecare.
Both organizations met on June 14 with Part C leaders at the Centers for Medicare & Medicaid Services.
Representing AAHomecare at the meeting were Tom Ryan, David Chandler, and General Counsel Cara Bachenheimer. The ALS Association’s Kathleen Sheehan, VP of Public Policy, and Cynthia Knoche, Director of Chapter Care Services, also attended.
In the announcement, AAHomecare said, “AAHomecare and the ALS Association shared their alarm at reports of increasing denials as high as 86 percent and 64 percent for two major plans, while other plans have denial rates in the low teens. Authorization issues are being seen for both new set-ups as well as for continued authorizations where patients have benefitted from NIV.”
The associations “asked CMS to promptly issue a memorandum clarifying medical policy and coverage of non-invasive ventilators and take steps to expedite NIV authorizations for people living with ALS,” the announcement said. AAHomecare added, “We will be following up with our request in writing and were encouraged by the willingness of CMS to work with the patient community, physician community, and AAHomecare to resolve this critical issue.”
The announcement reported that representatives of the ALS Association as well as clinicians “provided first-hand accounts of the devastating impacts that delays and denials can have on patients and their caregivers.” ALS Association representatives “drove home the notion that physicians who have examined and made a clinical assessment of a patient are best positioned to determine the type of respirator needed — not MA plan prior-authorization and utilization staff.”
The ALS Association is asking people with ALS and the clinicians they work with to share their experiences related to their efforts to acquire a non-invasive ventilator. The ALS Association will share these accounts with CMS, but patients can choose not to provide their full names, home addresses, and other personal information that they don’t want CMS to have.
