DME Prior Authorization Results: What the Approval Rate Leaves Out

DME prior authorization improper payment results count requests and decisions, but they do not isolate how much improper payment the program prevents. Medicare reviews coverage before equipment is delivered, giving it a chance to stop unsupported claims before payment. A supplier’s billing team still sees separate events behind the headline percentage: the request, the decision, the delivery and the paid claim. A file can carry a real clinician’s signature while concealing how that signature was obtained.

Does DME Require Prior Authorization?

Medicare requires prior authorization for selected durable medical equipment, prosthetics, orthotics and supplies. The Required Prior Authorization List names the items subject to review before delivery.

The Centers for Medicare & Medicaid Services program history shows the expansion in stages. The initial required program began with two power-mobility codes in four states in March 2017, then expanded those codes nationwide that July. Selected lower limb prosthetics followed nationwide in December 2020. Selected orthoses rolled out in phases during 2022. Comparing years means comparing a changing collection of products.

The supplier population can change too. The agency’s first supplier exemption cycle began June 1, 2026, allowing suppliers with provisional affirmation rates of at least 90% to qualify for exemption. Exempt suppliers leave the review pool, changing whose requests the results describe.

What Prior Authorization Actually Measures

Prior authorization reviews whether the submitted information supports Medicare coverage, coding and payment before the item is furnished. A provisional affirmation is an early decision about that request. The supplier still has to deliver the item and support the later claim.

The order, clinical record, authorization decision and delivery record answer different questions. The order identifies what the practitioner prescribed. The clinical record supports why the patient needs it. The authorization decision records the review. Proof of delivery connects the billed equipment to what the patient received.

That distinction matters when an internal report calls everything a denial. A request that was not affirmed, a later claim denied for payment and a claim overturned on appeal occur at different points. They need separate labels before their percentages mean much.

The Results Count Requests

For fiscal year 2024, the Centers for Medicare & Medicaid Services reported 193,140 requests received, 175,577 requests completed and 127,994 provisionally affirmed. It provisionally affirmed 72.9% of completed requests.

An insider reading an approval report needs to know whether it follows first submissions or includes resubmissions, and whether it follows the request through to payment. A corrected request and an initially complete request tell different stories about the supplier’s paperwork. An approval percentage alone loses that history.

The agency also reported contractor accuracy of 100% for the 960 reviews it checked that year. It cannot tell the reader how many false orders existed outside the review’s reach.

The distinction predates this program. In Waste, Fraud, and Abuse, a 2003 House Ways and Means Committee hearing, the General Accounting Office described its assessment of Medicare contractors:

Getting the reviewed decisions right and finding the claims that need review are separate accomplishments.

Why Did the Appeal Percentage Jump?

Medicare changed the comparison: its fiscal year 2022 appeal-overturn figure was 0.3% of all completed reviews, while its fiscal year 2024 figure was 38.4% of claims appealed to the first level. Those percentages cannot show whether appeals became more successful.

For a billing manager, the useful question is what changed between the initial submission and the eventual payment decision.

Power Wheelchair Spending Decline: Rental Payment Change Versus Prior Authorization

Prior authorization was not the only change affecting power wheelchair spending. Medicare’s power-mobility series shows half-year spending of $194 million in the period ending September 2012, when Medicare’s prior authorization trial began, and $96 million a year later.

Competitive bidding and the elimination of the lump-sum purchase option had both arrived in January 2011. Moving payment from an upfront purchase to rental installments changes when the money appears.

The payment category matters inside a supplier’s business. Standard capped rentals transfer title after thirteen paid months. Orthotics and prosthetics are purchased in a lump sum.

Prosthetics Rose, and the Orthoses Comparison Changed

Lower limb prosthetics spending rose across the period in which prior authorization began. Medicare reported $17 million in the first half of fiscal year 2020 and $37 million in the second half of fiscal year 2024. The agency attributed the increase to higher fee-schedule prices and broader coverage under local coverage policies.

The fiscal year 2024 orthoses report shows spending falling from $106 million per half year in early fiscal year 2021 to $12 million in early fiscal year 2024. The earlier publication covers different codes, so joining the two would change the products being measured.

What the Improper-Payment Rate Counts

The Comprehensive Error Rate Testing program measures whether sampled payments meet Medicare’s coverage, coding and billing rules. Missing signatures and insufficient clinical documentation can drive the result. It is a payment-compliance measure.

For fiscal year 2025, the Centers for Medicare & Medicaid Services reported an improper-payment rate of 24.12% for durable medical equipment, prosthetics, orthotics and supplies, compared with 6.55% for Medicare fee-for-service overall. The equipment and supplies category remained far above the program-wide rate.

The estimate covers claims submitted from July 1, 2023, through June 30, 2024, with substantial uncertainty around the rate.

For an insider investigating durable medical equipment fraud, the question reaches beyond the sampled paperwork. A convincing file can conceal the payment that bought the order.

The fiscal year 2025 supplemental report provides a particularly sharp example. The agency identified many urological-supply errors associated with payment suspensions for Operation Gold Rush as zero-dollar errors. They did not contribute to the improper-payment rate because payment had been suspended. A large attempted billing scheme and a payment-error estimate can therefore tell very different stories about the same product category.

Which Control Stopped the Payment?

Payment suspensions and claims-system edits can prevent payments without a prior-authorization decision. Their results belong to the controls that produced them.

In its 2026 report on Medicare fraud analytics, the Government Accountability Office described alleged catheter billing for items that were unnecessary and never provided. The Centers for Medicare & Medicaid Services said that its payment suspensions prevented over 99% of the payments in that episode.

A separate Department of Health and Human Services Office of Inspector General audit identified $22.7 million in improper supplier payments for equipment and supplies during inpatient stays in 2018 through 2024. The inpatient facility generally had responsibility for providing those items directly or arranging for them.

The inspector general found that improper payments fell substantially after Medicare changed its claims-system edits in January 2020. Even so, $4.5 million went out improperly from then through December 2024. The edit reduced the problem but kept letting improper payments through.

A Real Signature Can Hide an Unsupported Order

A genuine signature answers who signed. It does not answer whether the signer evaluated the patient or whether someone paid for the referral.

In a 2024 civil case involving an Iowa nurse practitioner, the government alleged that she signed brace prescriptions for patients she had never contacted. She received $20 per patient reviewed and spent as little as nine seconds reviewing a record, according to the government’s account. The allegations included a left knee brace prescribed for a patient whose left leg had already been amputated.

The alleged problem was the clinical story behind the signature.

The whistleblower’s complaint concerning Numotion describes a related problem: a therapist allegedly signed an evaluation without evaluating the patient. The complaint records the follow-up question:

For a health care insider, the signed form and the work it claims to document can tell different stories. The clinician’s records, the preparation of the form and the payments for obtaining orders are where that difference becomes visible.

What an Insider Sees Behind the Percentage

A supplier’s records can connect the first request, any resubmission, the decision, delivery, the claim and any appeal. That sequence shows where the story changed. A revised clinical justification raises a different question from a changed equipment code or a delivery record that contradicts the claim.

Healthcare billing and compliance staff also see parts of the business outside an authorization table: the marketer’s invoice, the order template, the clinician’s review and the instruction to keep billing. We connect those commercial decisions to the claims with you. A high approval rate does not answer who created the clinical account or why the supplier trusted it.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

When You Know What the Approval Missed

If you work in supplier billing, clinical review or compliance and know how an unsupported order became an approved file, talk with our whistleblower experts about the decisions behind it. We work beside you to build the case around the order, the money and the claims, and bring in durable medical equipment fraud whistleblower lawyers who understand the business behind the paperwork.