Modification, not elimination

It's never a good feeling when we send our January issue to the printers in mid-December and it has three stories about a new power mobility device demonstration, including a front-page story, and CMS decides on Dec. 29 to postpone said demo. I mean, it was good news for the industry, but bad news for HME News.

Upon learning the news, Theresa Flaherty said rhetorically: “Don't mind all of those stories on the PMD demo in our January issue. They're now obsolete.”

They are—and they aren't.

CMS still plans to move forward with the demo. But it has realized, based on the number of comments it received, that it had better take more time to think about how it wants to implement the demo. There may have been a hint that this was coming during a teleconference shortly after CMS's announcement. Officials were asked why they couldn't also start prior authorizations on Jan. 1, and they said their systems weren't ready to do that. They planned to buy themselves up to six months by starting off with something their systems were ready to do (prepayment reviews).

Of course, in CMS's eyes, prepayment reviews aren't just a warm up for prior authorizations. The agency believes this double-whammy is key to lowering a 75% error rate for PMD claims. CMS, not to mention the Obama administration and countless lawmakers, are hell bent on reducing fraud, and what taxpayer in his or her right mind can blame them?

If prepayment reviews remain part of the demo, however, it will be much to the chagrin of the HME industry, which would like CMS to drop them completely.

I guess there's no harm in shooting for the moon, but past experience with flawed CMS programs would indicate this strategy rarely works. For years now, the industry has worked tirelessly yet unsuccessfully to eliminate competitive bidding; only last year did it begin working to modify the program instead. The verdict's still out, but it wasn't until the industry starting talking modification instead of elimination that it has been taken seriously by some.

With that in mind, the HME industry might be better off if it took this delay in the demo as an opportunity to lobby CMS to reshape prepayment reviews, not drop them. The industry is already taking a more constructive approach to prior authorizations: It wants CMS to keep those, but allow providers, not physicians, to submit requests, and allow physicians to use templates to submit documentation.

So how can the HME industry take a more constructive approach to prepayment reviews? Should it lobby CMS to conduct reviews on a certain percentage of claims, instead of 100% of claims? Should it lobby CMS to complete reviews within a certain amount of time to minimize the impact on cash flow and access?

Think I've gone off the deep end? We've had more than one reader email us to say that the demo isn't such a bad move. One of our readers emailed me: “This program would be good for everyone, including patients, dealers and Medicare. We are idiots for fighting every proposed program that comes down the pike.”

CMS says it will give 30 days notice before it implements the demo. Whenever that happens, we're crossing our fingers that it aligns with our publishing schedule.

Liz Beaulieu