New demo scrutinizes PMD claims

WASHINGTON - The HME industry was blindsided this week when CMS announced that providers in seven states would need to go through prepay reviews and prior authorizations for power mobility device (PMD) claims.

"We had no idea this was coming," said Cara Bachenheimer, senior vice president of government relations for Invacare. "We still don't know a lot of the details—we're working to learn as much as we can about it and to understand what's required."

CMS will conduct a three-year demonstration project, beginning Jan. 1., with two phases: a first phase, lasting three to nine months, where all PMD claims will go through prepay review; and a second phase where all PMD claims will go through a prior authorization process.

Industry stakeholders question whether CMS can be ready for a Jan. 1 starting date.

"I don't see how they could set this program up in a month and a half," said Walt Gorski, vice president of government affairs for AAHomecare. "Nor do I think they have the ability to audit this many claims."

The demo targets providers in Florida, Texas, California, Michigan, Illinois, New York and North Carolina. Claims in those seven states accounted for 43% of total Medicare expenditures for PMDs in 2010. CMS estimates the demo will affect 325,000 claims.

Industry stakeholders have many questions regarding the announcement, among them: Will the demo include complex rehab? What will the prepay review and prior authorizations processes look like? What will this mean for providers and consumers in those states?

John Letizia, chairman of AAHomecare's Complex Rehab and Mobility Council, is among the stakeholders who believe the demo will result in access issues, especially when you consider it's on top of other recent changes like the elimination of the first-month purchase option.

"I don't know how any provider, small or large, can do prepay review for all PMDs," Letizia said. "We've been trying to still provide quality products and services, but people are just going to say, 'I can't do it anymore.'"

Gorski said AAHomecare plans to meet with CMS in early December to learn more about exactly what the demo entails.