CMS details PMD demo

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Thursday, December 1, 2011

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.

 

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Comments

So unless a doctor does something for a ridiculously low fee then the patient will not have access unless the provider takes a pay cut that makes no business sense whatsoever. So basically medicare's position will be that they will pay for chairs so long as providers are willing to lose money incrementally. Perfect! Wonderful!

This just validates the old joke. If the government is the answer, then it must be a really stupid question.

I think as providers we really need to do something about these jokers. We spend our money to put out these products. I think its about time we stand our ground and refuse these rules. These Idiots fail to realize we are running a business. If they feel they have the answers they should go ahead and render these services. This is getting really ridiculous. As it is we are already having issues getting paperwork from physicians, now you want to add additional burden on physicians, I refuse to believe CMS really have morons working there, I believe this is more of a conspiracy to simply push companies to the brink of bankruptcy and then leave 2 or 3 companies to provide services for these guys. This violates the capitalist society this great country was built on. Its ok for government to turn into a communist society when it benefits them.