Expand Prior Authorization Demonstration Nationally

CMS’s three-year Power Mobility Device (PMD) prior authorization demonstration is scheduled to expire Sept. 1 unless CMS or Congress take action later to continue what many have indicated is a successful program. The PMD prior authorization demonstration was initially implemented for physician orders written on or after Sept. 1, 2012 (for beneficiaries residing in CA, FL, IL, MI, NY, NC and TX). Last October, CMS expanded the demonstration to 12 more states (AZ, GA, IN, KY, LA, MD, MO, NJ, OH, PA, TN, WA). The products subject to the PMD demonstration include: Group 1 Power Operated Vehicles (K0800-K0802 and K0812); all standard power wheelchairs (K0813-K0829); all Group 2 complex rehabilitative power wheelchairs (K0835-K0843); all Group 3 complex rehabilitative power wheelchairs without power options (K0848-K0855); pediatric power wheelchairs (K0890 and K0891); and misc. power wheelchairs (K0898). CMS exempted Group 3 single and multiple power option complex rehab power wheelchairs (K0856-K0864) and options and accessories from the prior authorization demonstration. Having the documentation reviewed on the front end and receiving an affirmative decision from Medicare prior to providing the device to beneficiaries provides a high level of protection in the event of a medical necessity audit. In addition it has assisted providers in their efforts to educate the medical community on CMS’s documentation expectations for a PMD when the request is denied and the denial reason(s) are communicated to the physician and Medicare beneficiary. Since implementation, CMS has published two status updates on the PMD demonstration. The latest, published December 2014, showed a decrease in expenditures for power mobility devices in the demonstration states and nondemonstration states. Based on claims processed from the inception of the pilot on Sept. 1, 2012, through Nov. 14, 2014, monthly expenditures for the power mobility device codes decreased from $20 million in Sept. 2012 to $6 million June 2014 in the nondemonstration states and from $12 million to $3 million in the demonstration states. CMS stated the decrease in spending is due in part to “national DME providers adjusting their billing practices nationwide (not just in the demonstration states) and reflects providers complying with CMS policies based on their experiences with prior authorization in the demonstration states.” The decrease in spending can also be attributed to the mandatory rental of standard power wheelchairs, competitive bidding and ongoing audits. Unfortunately, the PMD demonstration authority expires Sept. 1, and we hear the final rule on DME prior authorization will not be released until late this year. Expanding PMD prior authorization nationally is a top priority. At the time of this writing, Rep. GT Thompson (R-Penn.) is planning to introduce legislation to expand the PMD demonstration national and apply it to all PMD codes. Contact your reps and request they cosponsor the bill. DME MACs are continuing to conduct audits of power mobility device claims in states outside of the demonstration in a “pay and chase” methodology. While they may conduct a prepayment review of claims even if the file has been affirmed through the prior authorization process, in these situations the MACs would focus on documentation that was not required during the prior authorization process. If CMS suspects a potential vulnerability, the MACs may request additional post-review documentation before the claim is paid. This gives providers a higher level of assurance that the delivered item will be reimbursed while protecting the Medicare Trust Fund.