More states join the PMD Prior Authorization Demonstration as progress continues

The Center for Medicare and Medicaid Services (CMS) has added 12 more states to the Prior Authorization (PA) demonstration for Power Mobility Devices (PMD). While there were some challenges and inconsistencies with the initial demonstration project that began in September 2012, CMS has improved certain aspects of the program during the past two years. Today, as the expansion gets underway, there is a comprehensive operational guide, a list of denial reason codes and statements, and the ability to submit the PA packet electronically. According to providers in the initial seven states, the program is generally working well.

The PMD and DME industries have long advocated for Medicare to utilize a practice of prior authorization as opposed to the long-standing practice of ‘pay and chase.’ For PMDs, PA demonstrations are now required in 19 states for orders written on or after Oct. 1, 2014.

The PMD PA demonstration project applies to all Medicare beneficiaries that have been prescribed one of the following PMDs by their physician: Group 1 power-operated vehicles, all standard power wheelchairs, all Group 2 complex rehabilitative power wheelchairs, all Group 3 complex rehabilitative power wheelchairs without power options, pediatric power wheelchairs and miscellaneous power wheelchairs.

Group 3 single- and multiple-power-option complex rehabilitative power wheelchairs are exempt from this project, but may still be submitted to the DME MAC jurisdiction for an Advanced Determination of Medicare Coverage (ADMC); however, these are two very different programs. The only beneficiary exception from the PA requirement is a representative payee on file with the Social Security office.

CMS reports that the expansion of the demonstration project will allow them to review approximately 70 percent of PMD claims prior to submission. When the determination is made the provider, beneficiary and physician are all notified in writing. Approved requests receive an authorization number that is also appended to the claim. In cases of denial, specific reasons are provided to physicians and their patients.

Prior authorization requests can be sent by mail, fax or electronically through Health Information Handlers (HIHs) that offer Electronic Submission of Medical Documentation (esMD) gateway services. Regardless of how the information is received, the turnaround time for an initial submission is 10 days, with 20 days provided for any resubmittals. Providers report that CMS has generally processed within these time frames, although the industry continues to advocate for quicker turnaround times. CMS and the DME MACs must continue to monitor the timeliness of prior authorization processing, since the timeframes that exist in the medical policy have not been adjusted for the demonstration project (e.g. a provider has 120 days from the date of the face-to-face to provide a PMD regardless of how long the prior approval process takes).

Another opportunity for improvement in the PA process is adding an electronic clinical template to allow vendor-created prompts to assist with documentation of the PMD face-to-face encounter for Medicare purposes. This initiative, called electronic Determination of Coverage (eDoC) is currently engaged in a pilot study designed to validate methods for implementing these templates, enabling medical professionals and PMD providers to create, share and provide documentation to CMS for the determination of coverage.

Clearly many benefits can be realized by a properly executed PA program for DME. A Medicare-proposed rule was issued in early 2014 regarding process expansion to other items of DME. Industry comments involved advancing a system in line with that of private payers. That program is expected early next year.

While the PA demonstration for PMDs will end for all states on Aug. 31, 2015, providers in the initial seven states have had a positive experience and expect the same as a result of this expansion due to the increase in audit protection and documentation certainty that the process provides.