Stakeholders await instructions on PA process

WASHINGTON - The cancellation of a Jan. 26 Special Open Door Forum on the upcoming prior authorization process for two complex rehab codes means industry stakeholders will have to wait longer to get their concerns and questions addressed.

During the forum, CMS was to outline the process for submitting a PA request to the designated Medicare Administrative Contractor, the timeframes for the MAC to render their decisions and the process for subsequent claim submissions.

“It's all unknown territory until CMS releases instructions,” said Martin Szmal, founder of The Mobility Consultants.

CMS in December announced K0856 and K0861 as the first two codes that will require PAs, as part of its goal of eventually requiring the process for a broader range of DME. The agency will implement PAs for the two codes in two phases: On March 20, it will apply the requirement to one state in each of the four DME MAC jurisdictions (Illinois, Missouri, New York and West Virginia); on July 17, it will expand the requirement to the remaining states.

CMS does have a PA process already up and running in 19 states as part of a demonstration project, mainly for standard power wheelchairs, though there are some Group 2 complex rehab codes included.

Chief among the concerns stakeholders have is the difference between the PA process and the advance determination of Medicare coverage process currently being used by many providers to help ensure payment for complex power wheelchairs. In the PA process, stakeholders suspect the clock will not stop on the 120 days that providers have to deliver products from the time of the face-to-face evaluation. In the ADMC process, providers have a six-month window to deliver equipment, which comes in handy when they need to re-submit claims or when they're configuring wheelchairs with accessories from several manufacturers.

“Now, more than ever, the supplier's documentation needs to be able to 'pass' the PA review on the first submission to ensure timely delivery of the equipment,” Szmal said.

The people reviewing claims as part of the PA process also have a different “skill set” than those reviewing claims as part of the ADMC process, stakeholders say.

“The ADMC reviewers have more in-depth clinical knowledge in regard to complex rehab,” said Sylvia Toscano, the owner of Professional Medical Administrators. “The PA process is a more simplistic approach.”

Stakeholders also pointed out that the ADMC process covers the base and accessories of a wheelchair, but it's unclear whether or not the PA process will do the same.

“If they're just approving the base and if the accessories are not medical necessary, then is the base not medically necessary?” Toscano said. “Are they going to expand the prior authorization to include all the codes that make up the chair?”

Additionally, stakeholders suspect that, like with the demo, CMS will automatically deduct 25% from reimbursement for claims submitted without prior authorizations.

“This is a step in the right direction, but providers need to be aware of these things that could—not go wrong—potentially be pitfalls,” Szmal said.