PMD Prior Authorization

On Sept. 1, Medicare implemented a power mobility device (PMD) prior authorization demonstration project in California, Florida, Illinois, Michigan, New York, North Carolina and Texas. It applies to physician orders written on or after that date for most PMD codes (K0800-K0855, K0890-K0891 and K0898) with the exception of Group 3 complex rehab power wheelchairs with power options (K0856-K0864). CMS made some last-minute changes to the PMD Demonstration Operational Guide on August 28 that incorporates more of what stakeholders have asked for. Per the changes, CMS will permit physicians’ use of templates to facilitate medical record keeping, the ability for them to add or clarify information post examination, the treatment of accessories and the process to follow for beneficiary upgrades.

PMD providers have been advocating for a system that reflects the structure of those already in place within nearly all state Medicaid and private insurance plans. The industry supports a timely and efficient process because it provides a level of assurance that, once approved, the reimbursement will not be subject to recoupment years later for insufficient documentation. Having more certainty is a step in the right direction, especially with the ongoing barrage of industry audits. While some may approach this change with caution, successful providers will capitalize on the opportunities it provides.

Tips to Manage the Process—As with any change, a transition period exists to make the system operate smoothly. Reviewing the medical record and interpreting the coverage criteria will be key to the process. Providers who have not already incorporated this practice may submit the seven-element order, face-to-face examination report, any additional medical records or relevant information and the detailed product description to the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for a prior authorization decision. The DME MAC will review the documentation, determine if the requirements have been met, and render a decision postmarked within 10 business days. With an affirmative decision providers can be more confident that they will be able to keep their money once the claim is processed.

Another option is to implement an internal documentation prescreen process, or utilize an external source before submitting it to the DME MAC. If the prescreen reveals compliance with the coverage criteria and the provider has a high level of confidence the prior authorization will be affirmative, the provider can capitalize on this. If the request is not affirmed, CMS will send a detailed letter outlining the documentation deficiencies to the PMD provider, physician and consumer. This provides an opportunity to obtain the documentation Medicare requires. The DME MAC may take up to 20 business days to process a resubmission. PMD providers who work closely with their referral sources and patients to obtain the missing information will not only learn from the experience, but will be in a better position to capitalize on the knowledge gained in the process.

Delays? Take Action!—During the early stages of implementation, many anticipate significant delays. The good news is that rather than the PMD provider being the bad guy, the physician and Medicare become the focus. To facilitate the process, a PMD provider can send a letter to beneficiaries whose prior authorization requests were not affirmed, explaining the new demonstration project and the reason for the delay. Tell customers that you are working with their doctor to acquire additional documentation, and make clear that such issues should not delay their access to the PMD. Consumers should be encouraged to call 800-MEDICAR(E) and their Senators and Representatives at 202-224-3121, to talk about the impact the delay in accessing the prescribed equipment is having on their life—lengthier stay in inpatient setting, inability to safely complete activities of daily living, etc.—and assert that it is not right to refuse prescribed care to a patient based on subjective review of a physician’s documentation to further support their prescription.

Congress and CMS have indicated that they want to hear about any extensive delays or denials of medically necessary PMDs. It is crucial that we as an industry provide them with this information in order to limit the demonstration’s negative impact during the transition period.