PMD demo: Could it help to increase access?

Friday, February 8, 2013

YARMOUTH, Maine – Provider Doug Westerdahl says one of the benefits of the PMD demo has been providing wheelchairs to Medicare beneficiaries that he never would have provided before.

Westerdahl has taken the demo’s prior authorization process as an opportunity to test claims he’s not sure whether or not CMS will approve.

“I was shocked that they approved a couple of them because the documentation talked about outdoor use,” said Westerdahl, owner of Rochester, N.Y.-based Monroe Wheelchair. “Those are ‘gray area’ chairs we never would have provided before (because we wouldn’t have been sure they would be approved.)”

Since Westerdahl has decided to use prior authorizations to test claims, his approval rate has gone down from about 98% at the start of the demo to about 75%, but he doesn’t mind. Those few approved “gray area” claims mean increased access to wheelchairs for beneficiaries.

Another unexpected bonus from the demo: The Medicaid program in New York, one of seven states where the demo is under way, is taking denied prior authorizations as claim denials, allowing patients to qualify for coverage sooner, Westerdahl said.

“It makes me wonder why any of us argued about the demo,” he said.

Provider Rick Perrotta agrees that there have been more positives than negatives with the demo. He says all of the claims he’s submitted have been approved and the affirmations have come in within CMS’s intended 10-day timeframe.

“This is going to be a win-win for doctors, patients and suppliers,” said Perrotta, president of Network Medical Supply in Charlotte, N.C. “There haven’t been any hitches or glitches or anything.”

Provider Craig Rae says he’s seeing more approvals than he was at the start of the demo, but some incorrect denials are getting him in hot water with patients.

“I had a complex rehab patient who said, ‘You told us you have everything you needed—you lied to me. I’m going somewhere else,’” said Rae, owner of Salisbury, N.C.-based Penrod Home Medical.

Rae did have everything the LCD required, he says, and the patient eventually returned to Penrod.

“This is just another hurdle to jump,” he said.

See also: PMD demo: CMS to offer reasons for denials

See also: CMS expands online submissions for PMD demo

See also: PMD demo: Approval rate improves