Under a demonstration announced in November, Medicare will implement a prior authorization process for all power mobility device claims in 7 high risk states—California, Illinois, Michigan, New York, North Carolina, Florida, and Texas. The purpose of the project is to circumvent the ability to get fraudulent claims through Medicare's claims payment systems.
The project will occur in 2 stages. During the first stage, claims for power mobility devices will be on 100% prepayment review beginning for dates of service on or after January 1, 2012. The second stage will implement prior authorization for these claims in which the durable medical equipment Medicare Administrative Contractors will review the claims and postmark a notification of denial or approval within 10 days. For more information, physical therapists can view the resources created by the Centers for Medicare and Medicaid Services for the December 2 special open door forum on this issue.
The APTA should respectfully request that the Centers for Medicare and Medicaid Services (CMS)’ delay the pre-payment review and prior authorization demonstration project for power mobility devices (PMD), announced November 15 and scheduled to be implemented January 1, 2012.
There is concern that the prepayment review process used in the PMD demonstration will cause an unnecessary disruption in access to mobility devices for individuals with disabilities and chronic conditions, and we should request that the agency delay implementation until an alternative, less disruptive process is arranged. The three-year demonstration project for power mobility devices requires a “prepayment review” of all power mobility claims submitted for payment. Unfortunately, this review occurs after the power wheelchair has been provided to and used by the beneficiary. With a considerable percentage of the currently high error rates reported on these claims being attributable to paperwork inaccuracies or omissions, suppliers are placed in the position of purchasing the power chairs, providing the chair and then potentially having to remove denied mobility devices from beneficiaries’ homes when the medical necessity may be genuine. If a review results in a denial of payment, the device could be rescinded from the beneficiary after use has begun, even if a review denial is in error.
The APTA could respectfully request that CMS delay the start of the demonstration to give the agency time to identify alternative approaches. One such alternative is to maintain the current, targeted pre-payment review program while working with power mobility stakeholders to develop a true the “prior authorization” program. The prior authorization program communicated by CMS requires the physician to submit for prior authorization for the power base rather than the supplier, which is not feasible. Prior authorization can be a very effective process since it occurs before the beneficiary receives the device. This system of the supplier submitting the required documentation for prior authorization is now in use by 49 of the nation’s State Medicaid programs, as well as by Medicare Managed Care Plans and TriCare. For these funding sources, the entire mobility system is authorized, not just the power base, which is a key component to pre-approving the request accurately.
With time for input from the public and stakeholders, CMS can develop an acceptable prior authorization process for the demonstration project that will not result in unnecessary access disruption for beneficiaries with genuine needs for their PMD.
Posted by Laura Cohen
on 12/16/2011 8:10 PM