Calif. claims may be hit with two reviews

Stakeholders hope claims won't need prepay and prior authorization
Friday, August 24, 2012

WASHINGTON – The industry hopes that the prior authorizations required by a new PMD demonstration project will eliminate the need for prepay reviews. That hope will face its first test in California.

The state is one of the seven states included in the three-year demo, which is slated to go live Sept. 1. It is also located in Jurisdiction D, which is currently conducting prepay reviews for a nearly identical list of power mobility codes.

“(CMS official) Melanie Combs-Dyer has indicated providers will not be subject to both,” said Seth Johnson, vice president of government affairs for Pride Mobility Products. “I would think California would largely be exempt from the reviews once the demo starts.”

The demo’s prior authorization process requires providers or physicians to submit documentation for approval before providers deliver equipment. Under prepay reviews, on the other hand, providers deliver equipment before documentation is reviewed.

The processes may be different, but the goals are consistent: ensure that claims meet Medicare’s guidelines before providers are paid, stakeholders say. 

“In essence, they’re really the same thing,” said Don Clayback, executive director of NCART. “If you’ve got a prior authorization, that really should take away the need for any prepay review.”

If providers do have to go through both, patients will be affected, says Simon Margolis, executive director of NRRTS. 

“There are going to be access issues, there’s no doubt about it,” he said.