PMD demo removes ‘mystery’

Friday, December 12, 2014

WASHINGTON – The expansion of Medicare’s PMD demonstration project has many providers tickled pink. 

The demo expanded to 12 additional states on Oct. 1, bringing the total number to 19.

“We applaud it,” said Terry Luft, CEO of Harrisburg, Pa.-based Dynamic Healthcare Services. “We are happy that we’re a part of the second demonstration.”

The newest states to join ranks: Arizona, Georgia, Indiana, Kentucky, Louisiana, Maryland, Missouri, New Jersey, Ohio, Pennsylvania, Tennessee and Washington. The states were chosen based upon a history of improper payments and PMD fraud, according to CMS.

The demo requires providers to submit prior authorizations for PMDs, which saves providers a lot of heartburn and headaches, they say.

“You can look at the consumer and say, ‘Yes, you qualify for this benefit and Medicare will pay,’ or ‘No, you do not qualify,’” said Luft. “They can then choose to purchase one on their own. The mystery is taken out.” 

One of the few complaints providers have is the extra time it takes to get authorization. 

Before the demo, providers would receive documentation from a doctor and provide the equipment. Now they must wait several weeks to see whether the patient qualifies.

But John Letizia, president of Laurel Medical Solutions based in Ebensburg, Penn., says for him, peace of mind outweighs the inconvenience. 

“It’s a heck of a lot easier to prevent (problems) upfront than it is on the backside,” said Letizia. “Quite frankly, it’s something they should have adopted a long time ago.”

One caveat: even with prior approval, there’s no guarantee that the provider won’t get audited. 

“Just because the claim was prior approved, doesn’t mean it can’t be subject to post payment review and recoupment after the fact,” said Sylvia Toscano, owner of Professional Medical Administrators. 

The demo is slated to end August 2015.



If you submit your PA request via ESMD, you can get your decisions in 48 hours. Some of the ESMD vendors have the capability to retrieve the decisions electronically. However, I do suggest providers contact Medicare to confirm the decision received electronically is accurate or they can just wait on the letter in the mail.