Prepayment audits for medtech are coming. Are you ready?

Contributors: Karen Gierszewski and Sara Scharf

Physicians have been reacting to the news that the CMS is rolling out a new pre-reimbursement review system across 11 states. This system would involve challenging doctors for proof that a procedure is necessary before granting reimbursement, which is a significant change from the status quo—where payments are granted and then investigations into any potential fraud are conducted at a later date.

Although exact details into these prepayment audits are still lacking, it seems that they will mostly target cardiovascular and orthopedic procedures, such as pacemaker/defibrillator implantations, percutaneous coronary interventions, spinal fusions, and large-joint replacements. The increasing scrutiny of these procedures could potentially affect device sales because doctors may not feel that they can adequately justify using a device or may find the process too inconvenient if other alternatives are available. The exact implications will become clearer as more details on the process become available and as the trial run in the first 11 states is rolled out.