PMD Demo Project Conference Call Reveals Details, Provider Concerns

• By Laurie Watanabe
• Feb 28, 2012

A Feb. 23 Open Door Forum about Medicare's upcoming power mobility device (PMD) demonstration project revealed additional details about the program and confirmed other previously mentioned ones.

It also gave providers the chance to ask questions and express a range of concerns.

Last week's Open Door Forum, led by Barbara Cebuhar of the Center for Medicare & Medicaid Services' (CMS) Office of Public Engagement, was one in a monthly series of Forums on the PMD demonstration project.

The project, unveiled in mid November, was originally scheduled to begin on Jan. 1, but in late December, CMS announced a postponement.

Last month, CMS said the project would start on or after June 1, 2012. The project affects most power mobility devices - power chairs and scooters - purchased by Medicare for beneficiaries in seven states with large populations of Medicare beneficiaries: California, Florida, Illinois, Michigan, New York, North Carolina and Texas.

CMS has repeatedly noted that the seven states generate 43 percent of all Medicare PMD claims.

"High Evidence of Fraud"

The Feb. 23 Open Door Forum, Cebuhar said, was "to provide an opportunity for suppliers and physicians to hear a little bit more about the Medicare prior authorization of power mobility device demonstration and to get an opportunity to ask more questions."

Cebuhar added that stakeholders who weren't able to ask questions during the call could e-mail questions to pademo@cms.hhs.gov. General information about the project is also available, Cebuhar said, at go.cms.gov/PAdemo.

Joining Cebuhar on the call were Melanie Combs Dyer, CMS' deputy director, provider compliance group; and Amanda Burd and Doris Jackson, whom Cebuhar referred to as health insurance specialists.

"I want folks to know that one of the primary reasons we're conducting this demonstration is because of fraud," Dyer said. "Power mobility devices have had a high rate of improper payment and fraud historically, and the states that we've chosen for this demonstration have historically demonstrated a high evidence of fraud."

During the Forum, she repeatedly referred to the seven states as highly prone to fraud and errors for PMD claims.

"The error rate for power mobility devices is over 80 percent, according to a recent OIG report," Dyer said.

The demonstration project therefore, Dyer said, "seeks to develop improved methods for the detection and investigation and prosecution of fraud in order to protect the Medicare trust fund."

Coverage Criteria Will Not Change

Dyer pointed out that Medicare was not creating new coverage criteria for PMD.

"The same coverage criteria requirements that are in place today are the same requirements that will be in place for the demonstration," she said. "We are not creating any new documentation requirements for physicians, practitioners or suppliers. We're simply asking that the information be submitted earlier in the process."

Though she stressed that providers and physicians were not being asked to do additional work - only to submit their documentation earlier in the process -- Dyer acknowledged during the Q&A session that the DME MACs are hiring more people in response to the demonstration project.

"We have been working with the DME MACs very closely, and they are all aware of the changes that they need to make to get staffed up and to get their fax lines ready to receive more faxes," she said. "They're all set and ready to go."

Advance Beneficiary Notice of Noncoverage (ABN) procedures would remain unchanged, Dyer added.

Dyer confirmed the project would start on or after June 1, but said, "CMS is planning on issuing a Federal Register notice on or about May of 2012 announcing the actual start date of this demonstration. We're expecting that the demonstration will begin for orders written on or after June 1, 2012. We're not firm on that date of June 1, 2012; that's what will be announced in the Federal Register notice that we're expecting to come out in May."

And per an earlier announcement, Dyer said all seven participating states are now expected to start "at approximately the same time."

She said the project would last three years: "It will add about three years after it begins in all seven states."

Borrowing a Page from Private Payors?

In explaining the structure of the demonstration project, Dyer said, "We want to try using private-sector methodology to protect the Medicare trust fund. Medicare has never really had a prior authorization program for any of the Part B or DME services, so we're hopeful that this procedure, a prior authorization that's used by Medicaid and many private-sector insurance companies, may be helpful to protect the Medicare trust fund."

This new prior authorization structure differs from the original demonstration project plans, which called for 100-percent prepayment reviews as the first phase of the project, followed by prior authorization in the project's second phase.

Because of supplier feedback expressing concern over the cashflow impact that prepayment reviews would cause, Dyer said, CMS has eliminated the prepayment review phase and will launch the project using only the prior authorization phase.

The prepayment reviews would have required suppliers to deliver PMD to beneficiaries, wait for the DME MAC to ask for additional documentation to support the claims, provide the additional documentation to the DME MACs, then wait to hear whether or not the DME MACs would pay the claims.

Under prior authorization, a provider will submit documentation for a PMD claim, then wait to hear if Medicare intends to pay the claim before delivering the PMD.

"A lot of suppliers suggested in their comments that the 100-percent prepayment review phase of the demonstration would be quite onerous and burdensome because they would be out the money for so long while the prepayment review was occurring while the item had already been delivered to the patient's house," Dyer said. "They encouraged us to jump straight to prior authorization."

Another concern raised, Dyer said, was that an ordering physician "may not be in the best position to actually submit the prior authorization request paperwork," as originally required. She said the prescriber or the provider acting on behalf of the prescriber will now be allowed "to perform the administrative function" of submitting the prior authorization request."

Stakeholders also objected to the "limited notice" given prior to the start of the project, Dyer said. That feedback led to the postponement of the start of the project to June or later.

Following a review of changes to the demonstration project, the CMS representatives took questions from attendees who'd called in.

Q&A: Providers Voice Their Concerns

Among the questions asked by callers:

Q: There is currently a 120-day requirement for final delivery of product after the face-to-face examination is complete. How does the prior authorization process - which takes 10 days for the claim to be approved or denied the first time, and additional time for resubmissions of the claim if it is initially denied - impact the 120-day delivery requirement?

Dyer answered, "The 120-days-to-deliver requirement does not change, so we would hope that any resubmissions that need to occur would happen fairly quickly.... If you want to submit another prior authorization request, a second, a third, a fourth, you certainly can, I guess, until you get up to that 120-day mark. And then I suppose the patient would need another face-to-face visit."

Q: Prior authorizations used by private insurance companies usually have a 48-hour turnaround policy and use electronic submissions using a standardized format. Why didn't Medicare adopt this model to automate the process, since it seems to be difficult to process this much paperwork?

Dyer said, "We are looking at adding an electronic submissions component to our system in the future. We will not have that in place (on June 1), but we will certainly try to get that in place as soon as we can after that."

Q: When can we get a G code (payment code used by physicians) for ATPs? When you're dealing with complex rehab, it does take a lot of time to do a proper evaluation with a client, and there are a lot of costs associated with that. The traditional answer is that it's all included in the HCPCS code for your payments, but I'm throwing this out there as you're structuring this whole new system. It seems fair and reasonable that there's some sort of reimbursement for that clinical expertise to be involved in the evaluation. It is a requirement to have an ATP for certain groups of wheelchairs.

Dyer said, "If you send me that request by e-mail, I'll certainly forward it on to our payment policy folks, and I suspect they would say the payment for that kind of work is already built into the fee schedule, but perhaps they would consider reducing the fees and adding additional payments for those professionals."

Q: Given that CMS is quoting an 80-percent error rate in current PMD claims, does CMS anticipate denying approximately the same ratio of prior authorizations for PMD?

Dyer said, "We're hoping that perhaps by reminding people up front that they have to go through this prior authorization process that it will make them pay a little closer attention to the rules and maybe act as a deterrent effect. Perhaps they'll recognize they don't meet the coverage requirements and won't go through the process."

Q: Does the 10-day turnaround time for the DME MACs to go through the prior authorization process and give the provider an approval or disapproval refer to 10 calendar or business days?

CMS indicated the 10-day period refers to 10 business days, meaning the process could take closer to two weeks when weekends are figured in.

Q: Will an approved prior authorization protect that claim from future post-payment reviews? Can another auditing body down the road overrule the DME MAC's determination if the DME MAC has approved a prior authorization?

Dyer answered, "For the medical necessity and the kinds of issues that are being reviewed during the prior authorization process, you will not be subject to post-payment review for those purposes by the MACs or the RACs. It is possible that that claim could get chosen by the CERT contractor; it's also possible that that claim might be chosen by a fraud fighter, like a ZPIC or a PSC. But the MAC or the RAC will not choose that claim for those purposes.

The next PMD demonstration project Open Door Forum is scheduled for 3 p.m. Eastern, Wednesday, March 21.