CMS details PMD demo
WASHINGTON - Physicians and practitioners, not HME providers, will submit prior authorization requests for power mobility devices (PMDs) to CMS in the second phase of a new demonstration project, officials told listeners during a Dec. 2 Special Open Door Forum.
In the first phase of the demo, starting Jan. 1, all PMD claims submitted by providers will be subject to a prepay review process. But in the second phase, scheduled to begin three to nine months later, physicians and practitioners will bear the responsibility as part of a prior authorization request process. They will receive reimbursement of about $10 per request for additional time spent preparing and submitting requests.
"Improper payments is really what this is all about," said Melanie Combs-Dyer, deputy director of CMS's Provider Compliance Group, citing an error rate of 75% for PMD claims.
CMS announced on Nov. 16 that it would conduct a demo involving prepay reviews and prior authorizations for PMDs in seven states. It scheduled a call Dec. 2 to discuss the demo with providers, and a Dec. 5 call to discuss it with physicians and practitioners.
Providers will receive a three-month notice before CMS transitions the demo to the second phase. They will still need to work with physicians to select equipment, CMS officials said.
The DME MACs will review prior authorization requests from physicians and respond within 10 days. If they deny a request, it may be resubmitted and they will respond within 30 days, CMS officials said.
If a provider receives a referral for a PMD and the physician hasn't gone through the prior authorization request process, the provider may still submit a claim to CMS, but he will be paid 75% of the current fee schedule amount, CMS officials said.
The first phase of the demo won't be much of a change for providers that are already under prepay review as part of other fraud and abuse efforts, CMS officials said.
"It's pretty much what's happening today," said Dyer. "It's just happening 100% of the time."
Providers concerned about putting out equipment with no guarantee of payment may go though the advanced determination of Medicare coverage (ADMC) process, CMS officials said.
CMS plans to issue a flow chart outlining the process for the second phase of the demo and an FAQ.