CMS on PMD demo: Denials increase, spending drops

Friday, May 3, 2013

WASHINGTON – Stakeholders say CMS’s recent update on the PMD demo doesn’t paint the whole picture.

On April 23, CMS reported that roughly 50% of the 12,000 prior authorization requests submitted through March 2013 were denied. Pride Mobility’s Seth Johnson suspects that fail rate only refers to initial requests.

“It does not appear to include resubmittal,” said Johnson, vice president of government affairs. “If you’re really going to paint a clear picture, you need to have all the data.”

Johnson would have also liked to see the most common reasons for these denials—a telling detail CMS did not include in the update, he says.

This is first update CMS has issued on the program since it began requiring prior authorizations for PMDs in seven states Sept. 1, 2012. The agency also reported that spending on PMDs in these states dropped from about $15 million in January 2012 to $7 million in December 2012. Spending in non-demo states also dropped, from about $23 million to $17 million over the same timeframe.

AAHomecare’s Peter Rankin says the update glosses over some industry concerns about consistency among reviewers and response times. CMS reported that it has been reviewing requests within 10 days.

“CMS says they’re conducting reviews in a timely fashion, but we know that sometimes responses aren’t received for 17 or 18 days,” said Rankin, manager of government affairs.

Despite these issues, stakeholders agree with CMS that, overall, the demo has been a positive experience so far.

“CMS seems happy and suppliers are happy,” said Don Clayback, executive director of NCART. “During the first months of implementation, there has been a lot of learning going on. It’ll be interesting to see data after a full year.”