Capitalizing on the Opportunity of the PMD Prior Authorization Demo
- By Seth Johnson
- Oct 01, 2012
For years, power mobility providers have
been advocating for Medicare to establish
clear and objective coverage criteria
and documentation requirements to assist
physicians and clinicians in capturing
the necessary elements in their medical
This effort has increased due to the high
audit activity that currently surrounds
power wheelchairs, especially those coded
K0823. Providers have struggled, second
guessed themselves, reduced or stopped
providing these medically necessary
devices to Medicare beneficiaries due to the
increased risk of payment recoupment.
While the vast majority of claims that
are denied in audits are ultimately overturned
for payment through the appeals
process, this calls a physician’s evaluation
and documentation methods into question
and compromises a power mobility device
(PMD) provider’s ability to dispense the
prescribed, medically necessary device.
Opening Lines of Communication with Referral
Many successful providers have put procedures in place to closely
review the medical records, interpret the coverage criteria, educate
physicians, clinicians and Medicare beneficiaries, communicate
potential errors or omissions in the documentation received, and
“audit proof” their files. While this strategy has taken its toll to
some degree on the relationship providers have with their referral
sources and further stresses the bottom line, it has helped open lines
of communication with referral sources and has yielded success for
providers in their ability to keep the reimbursement received.
To proactively address the situation, power mobility stakeholders
have been asking the Centers for Medicare & Medicaid Services
(CMS) to institute a true prior authorization (PA) process in the
Medicare program for years. The agency is finally embarking on this
with a demonstration project that started Sept. 1 for those providing
PMDs to individuals who reside in California, Florida, Illinois,
Michigan, New York, North Carolina and Texas. While some may
approach this change with caution, successful providers will seek to
capitalize on the opportunities it affords.
Reviewing the medical record and interpreting the coverage
criteria will be a key part of the process for a PMD provider in the
prior authorization setting. Providers who have not already incorporated
this practice into their business model may submit the
seven-element order, face to-face examination report, any additional
medical records they receive, 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 submitted, determine if the statutory
and medical necessity requirements have been met, and render
a decision to be postmarked within 10 business days of receipt of the
information. With an affirmative decision, providers can rest assured
that as long as their delivery documentation is in order, and they are
not subject to an audit for any other reasons, they will be able to keep
their money once the claim is processed.
How to Use Prior Authorization to Streamline Your
While this approach takes all of the pressure off the providers, it does
have the potential to delay their ability to capitalize on the process if
an affirmative decision is not rendered following the initial submission.
Providers included in the demonstration who have not already
done so would be wise to implement an internal process to review this
information prior to submission to avoid such an occurrence when
Providers who either implement an internal prescreen process, or
utilize an external source for prescreening the documentation before
submitting it to the DME MAC for prior approval, have the opportunity
to manage the outcome of the order more effectively. If the
prescreen reveals compliance with the medical necessity requirements
and the provider has a high level of confidence the prior authorization
will be affirmative, the provider can capitalize on this.
By ordering the equipment from the manufacturer and having it
in stock and ready for delivery when the official decision is received,
the provider is able to minimize their patient’s delay in access to
the equipment and maximize their ability to bill and collect for it.
If a perceived error or omission is found in the prescreening of the
medical record(s), the provider will be well aware of the probability
they will receive a non-affirmative decision upon initial submission of
the prior authorization request and can plan accordingly.
Educating physicians, clinicians, and Medicare beneficiaries on the
actual errors and omission of information in the medical record is far
more acceptable than trying to communicate what you “think” might
be perceived as missing in the event of an audit. If a non-affirmative prior authorization decision is rendered, it does not mean that the
beneficiary does not have a medical need for the device. It simply
means that the information submitted was incomplete or the reviewer
was unable to affirm that the contemporaneous medical record
substantiated the need for the device to warrant payment from the
Medicare trust fund. In this situation, the physician, beneficiary and
provider should expect to receive a detailed review results letter that
“gives all the details about what was missing,” according to CMS.
A Teachable Moment for Physicians
Providers who have prescreened the documentation prior to submission
can anticipate what information will be deemed missing and will
be able to work with the beneficiary and physician in an expedient
manner to obtain the additional information necessary to resubmit
the prior authorization request.
For those who have not reviewed the documentation prior to
submission, CMS stated on the July 27 PMD Prior Authorization
Open Door Forum call, “The most important part of physician education
that we are instituting here is the detailed review results letter. There’s nothing like sort of having it hit you in the face when it does.
It is an individual beneficiary, one that you just saw a couple of weeks
ago. Now you’re being told no, it’s not prior authorized, (which is) one of the best educational pieces that we could have put in place.”
Having CMS directly tell a physician what is missing or incomplete
will relieve the HME provider of the burden of playing “middle man”
in the prescribing process, which is what currently exists.
While the prior authorization resubmission process will take up
to 20 business days for the DME MAC to render and postmark the
new decision letter, providers who work closely with their referrals
sources and patients to obtain the missing information will not
only learn from the experience, but be in a much better position to
capitalize on the knowledge gained in the process. As stakeholders
become more familiar with the process, it will allow providers to
more effectively manage future orders and reap the benefits of recurring
revenue without the worries of an audit and recoupment of the
This article originally appeared in the October 2012 issue of Mobility Management.
About the Author
Seth Johnson is the vice president of government affairs for Pride Mobility Products Corp. He is a board member of the National Coalition for Assistive and Rehab Technology (NCART), a former chairman of the American Association for Homecare's Complex Rehab and Mobility Council (CRMC), and is active within several state associations and various other industry stakeholder organizations and coalitions. He can be reached by voice at 1 (800) 800-8586, or online by visiting www.pridemobility.com.