PA program spreads out

Stakeholders continue to laud program, but they’re still keeping an eye on it
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Friday, August 24, 2018

WASHINGTON – Industry stakeholders expect it to be mostly business as usual on Sept. 1, when CMS is set to expand a demonstration project requiring prior authorizations for standard power mobility devices nationwide.

Prior authorizations for these devices were previously required in 19 states.

“We remain optimistic because the demonstration has been mostly successful so far,” said consultant Sylvia Toscano, owner of Professional Medical Administrators.

Already part of the National PA Program: complex rehab codes K0856 and K0861.

When any program is expanded, however, there are likely to be hiccups, and in the weeks prior to Sept. 1, consultant Martin Szmal says he’s seen several signs of growing pains, including a request for a DME Information Form, or DIF, even though those aren’t required for wheelchairs, just enteral nutrition and pumps.

“I think they’ve started to ramp up already, and we’re seeing some odd replies and requests for additional documentation,” said Szmal, founder of The Mobility Consultants. “I think the people they’re training—it’s not any fault of theirs, they’re just new to the policies and the nuances to them.”

What these growing pains mean is a longer turnaround time for approvals for prior authorization requests, Szmal says.

“We call and explain, and we ask them to reverse their decision,” he said. “They say, ‘We have to look into it,’ and that takes two weeks.”

At least this might be a sign that CMS’s contractors are ramping up staffing to meet the needs of an expanded prior authorization program, something that has been a top concern of stakeholder Don Clayback going into Sept. 1.

“(The contractors) are taking on new volume, and they need to keep staffing in mind,” said Clayback, executive director of NCART. “CMS has a system that’s working, so that’s the only caveat.”

The system is working, but it’s still deficient in one important way, Toscano says: Prior authorization approvals don’t cover the accessories that are submitted along with bases. In the previous Advanced Determination of Medicare Coverage or ADMC process, they were.

“There’s still a void where accessories are concerned,” she said. “I’m not sure why (they won’t budge on accessories). Maybe because instead of looking at one LCD, you’d have to look at three or four LCDs and NCDs and policy articles, and they’re thinking about the time reviewers have to spend on this.”

To prevent a provider from providing accessories only to have them denied down the road, Toscano says she’s dotting her Is and crossing her Ts before submitting them with a base for prior authorization approval.

“We’re trying to prevent everything we can on the front end,” she said. “We don’t put it out to begin with unless we’re certain.”