CMS Unveils Cover Sheet, Flow Chart for PMD Demo

The latest Open Door Forum about the upcoming Medicare power mobility device (PMD) demonstration project revealed some additional information, as well as continued concern being felt by mobility suppliers.

The Centers for Medicare & Medicaid Services (CMS) hosted the March 21 conference call, which was chaired by Barbara Cebuhar from the office of public engagement. Joining Cebuhar on the call once again were Melanie Combs Dyer, CMS' deputy director, provider compliance group; and Amanda Burd and Doris Jackson, whom Cebuhar described as health insurance specialists.

Dyer reiterated that the demonstration project - which will require prior authorization for most scooters and power chairs in seven states - will begin on or after June 1, 2012, but added, "We do not have our firm start date yet."

Dyer said the exact start date would be published in the Federal Register, but did not offer details about when the publication would happen. She did say the demonstration project would involve orders written on or after June 1.

The seven states involved in the project are California, Florida, Illinois, Michigan, New York, North Carolina and Texas. Dyer referred to them as "seven high-fraud states."

Members of the DME and complex rehab technology industry have repeatedly objected to that characterization, contending that errors found on claims should not automatically and generically be defined as attempts at fraud.

Decision Letters Will Be Sent

The PMD affected by the demonstration project are:

-- Power-operated vehicles (aka, scooters): HCPCS codes K0800-K0805 and K0809-K0812.

-- Standard power chairs: HCPCS codes K0813-K0829.

-- Group 2 complex rehab power chairs: HCPCS codes K0835-K0843.

-- Group 3 complex rehab power chairs without power options: HCPCS codes K0848-K0855.

-- Pediatric and Group 4 power chairs: HCPCS codes K0887-K0891.

-- Miscellaneous power wheelchairs with HCPCS code K0898.

PMD claims from suppliers in the seven participating states will be subject to prior authorization review by the DME MACs. The DME MACs will "affirm" or "non-affirm" the claim and will send a decision letter within 10 business days to the prescribing physician or practitioner; the Medicare beneficiary; and the supplier.

Dyer said decision letters for non-affirmed claims would include a "detailed written explanation" of the DME MACs' decision. The supplier can resubmit the claim an unlimited number of times, and DME MACs will have 30 days to process the subsequent requests.

Drafts of New Documents

Amanda Burd introduced the first draft of a Suggested PMD Prior Authorization Cover Sheet for suppliers in the PMD demonstration project to use. The cover sheet includes such information as the beneficiary and physician/practitioner name; supplier name; whether the documents are being submitted for review for the first time or are being resubmitted; and whether or not the supplier is asking for the request to be expedited.

The Cover Sheet also includes a brief documentation checklist of the information that needs to be included: the face-to-face exam progress notes; seven-element order; detailed product description; and other relevant medical documentation.

Burd said CMS is seeking comments on the Cover Sheet draft. Comments can be sent to pademo@cms.hhs.gov.

Burd also unveiled a process flow chart that envisions how the prior authorization process would work. The flow chart and cover sheet are available for downloading at go.cms.hhs.gov/PAdemo.

The flow chart includes scenarios for claims that are affirmed and non-affirmed, as well as for claims submitted by suppliers currently participating in Medicare's round 1 competitive bidding project.

Suppliers who are not involved as competitive bidding contracted providers can choose to skip the prior authorization process, even if they operate in the seven demonstration project states. But their PMD claims, if they are approved, would be paid at only 75 percent of the current allowable.

Stakeholders Concerned About Delivery Timeline, Additional Audits

During the question-and-answer portion of the call, industry stakeholders repeatedly expressed concern over how the prior authorization process could impact a supplier's ability to deliver PMD within Medicare's mandated timeframes.

The CMS representatives on the call repeatedly said an affirmed prior authorization decision would not expire. However, multiple callers said they were worried that the time involved in getting a prior authorization affirmation - especially if resubmissions are necessary - would make it difficult or impossible to deliver the equipment in the time demanded by Medicare.

When callers asked if Medicare would extend delivery deadlines for suppliers in the seven demonstration states, the CMS representatives said no.

CMS representatives also reiterated that suppliers who receive affirmed decision letters may still be subjected to audits later on by different contractors, such as those monitoring program integrity.

The next Open Door Forum on the PMD demonstration project is April 26 at 3 p.m. Eastern.

About the Author

Laurie Watanabe is the editor of Mobility Management. She can be reached at lwatanabe@1105media.com.

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