PMD demo: There's still work to do

Thursday, February 9, 2012

WASHINGTON - The mobility industry scored a major win earlier this month when CMS dropped the prepay review phase of a PMD demonstration project that it now plans to start on or after June 1.

But stakeholders know the devil is in the details. NCART Executive Director Don Clayback wonders, for example: How will the remaining phase, which requires prior authorizations, work; what will CMS require from providers; and what will be the response times?

"The concern is, we don't want to delay the equipment," he said.

CMS has also decided that providers, not physicians, will submit requests during the prior authorization phase.

This last change will put control of the process in the hands providers, where it belongs, says Cara Bachenheimer, senior vice president of government relations for Invacare.

"That's exactly who should be doing it, because he or she will make sure it happens," she said. "These are two hugely positive changes."

Other work that needs to be done to the demo, stakeholders say: Carving out complex rehab, and creating a clinical medical necessity template.

"We're continuing to work with the power wheelchair community--clinicians, suppliers and physicians--to create a workable program here," said Walt Gorski, vice president of government affairs for AAHomecare. 

The template would help physicians fulfill all of Medicare's requirements, creating a claim that would hold up to an audit. 

"Forty-nine state Medicaid programs and a significant number of private insurances require prior authorizations, and they all have some type of template," said Seth Johnson, vice president of government affairs for Pride Mobility Products.

Other changes that CMS made to the demo include allowing a 60-day public comment period on reducing paperwork burdens, and starting the demo at approximately the same time in all seven states.



Yes, but the 49 state medicaid programs and the various private insurance companies that use PAs do not have nearly as heavy of a hand when it comes to reviews. Hopefully CMS will be constructive and not just use this as an excuse to deny 90% of the claims that are filed.