Ahead of expansion, PA process runs smoothly

Providers report reasonable turnaround times, decent affirmation rates
Friday, June 9, 2017

WASHINGTON – CMS plans to expand a prior authorization process for two complex rehab codes nationwide on July 17 and the agency, for the most part, has the blessing of industry stakeholders.

CMS flipped the switch on a PA process for K0856 and K0861 in Illinois, West Virginia, Missouri and New York in March.

“From what I’m hearing from our members, it’s going smoothly,” said Don Clayback, executive director of NCART. “From the start, we’ve been supportive of prior authorizations, as long as the process goes smoothly.”

It helps, stakeholders say, that CMS already has a PA process in place for standard power wheelchairs as part of a demonstration project that’s now running in 19 states. The agency worked with stakeholders early on to tweak the process to make it more manageable for providers.

Providers like Chuck Spiedel report that their PA requests for K0856 and K0861 are getting affirmed or non-affirmed within two weeks, a turnaround time they’re pleased with.

“That’s reasonable,” said Spiedel, the rehab manager for Personal Mobility in Springfield, Ill. “Even managed care takes at least that amount of time.”

Providers like Doug Westerdahl also report that the majority of their PA requests for K0856 and K0861 are getting affirmed. Overall, his company’s affirmation rate is 49%, but when he weeds out the requests for standard power wheelchairs that are part of the demo, it’s probably higher than that, he says.

“My guess is the approval rate for the complex rehab codes is 60% to 65% on the first try,” said Westerdahl, president and CEO of Monroe Wheelchair in Rochester, N.Y.

Even when their requests are non-affirmed, providers are typically able to get them affirmed with subsequent requests, they say.

“The non-affirmations are usually due to transmission issues, not documentation issues,” Spiedel said. “Like something got cut off in the fax and we need to resubmit.”

Providers do worry, however, that when CMS expands the PA process nationwide, it may strain the process.

“I’m very worried about that,” Westerdahl said. “Right now, if we don’t get something back in 10 business days, we can call and find out if we’ve been approved or denied. If they tell us we’re approved, we don’t wait for the mail; we go ahead and order the chair.”

Weesie Walker, who like Clayback heads up an organization representing complex rehab providers, says she hasn’t heard anything negative about the PA process.

“I think, for the most part, providers are in favor of it,” said Walker, executive director of NRRTS.