PMD demo: CMS to offer reasons for denials

Friday, January 18, 2013

WASHINGTON – Industry stakeholders say help is on the way for providers who are still getting denials for prior authorization requests submitted as part of the new PMD demo.

CMS is collecting comments on a list of reason statements that spell out exactly why prior authorization requests are denied, giving providers a better idea of what needs to be fixed before resubmitting them.

“These are definitely going to help,” said Peggy Walker, a billing and reimbursement adviser for U.S. Rehab. “They are breaking it down into about 25 different codes just for the 7-element order alone.”

Stakeholders hope to see the reason statements in effect by this spring.

In the meantime, providers have another chance to make the prior authorization process a little smoother: Starting this month, providers in Jurisdictions A, C and D can submit requests through the electronic submissions of Medical Documentation (esMD) system. That means time spent waiting for requests to make their way (or get lost) through the mail and fax systems could be things of the past, says Seth Johnson, vice president of government affairs for Pride Mobility.

With or without these improvements, providers and CMS contractors seem to be getting the prior authorization process down, Johnson says.

“We’ve seen slightly higher approval rates on first submission, and 85% to 90% approvals on resubmissions,” he said.

Providers have had a good experience overall, says Pete Rankin, manager of government affairs at AAHomecare.

“There’s enthusiasm for this process, depending on how CMS goes forward with the program,” he said. “As long as it’s an effective system, it can help ensure beneficiary access.”