On November 15th, the Centers for Medicare and Medicaid Services (CMS) announced a widespread, three-year demonstration project that would, effective January 2012, require “prior authorization” for approval of power mobility devices for Medicare beneficiaries in seven states –– California, Florida, Illinois, Michigan, New York, North Carolina and Texas in which more than 43 percent of Medicare wheelchair users reside.
This CMS announcement was made without notice to Congress, Medicare beneficiaries, their physicians or the durable medical equipment (DME) suppliers. United Spinal Association has serious concerns that the project will contribute to confusion and chaos in the name of reducing expense and has asked that the project not be implemented.
Last week, United Spinal wrote a letter to key members of Congress and the CMS Administrator to oppose the project’s initiation, demanding a more thorough process for public input be provided and urging CMS to work with Congress and power mobility stakeholders to identify alternative approaches that will fulfill CMS’ interests in reducing overpayment and fraud and abuse without potentially creating significant disruptions of services to the disability and aged communities.
The first phase of the project requires a “prepayment review” of all power mobility claims submitted for payment. The problem is that this review will occur after the power wheelchair has been dispensed and begun to be used by the beneficiary.
CMS should not restrict access to medical care or rescind care that has already been provided. With a considerable percentage of the currently high error rates reported on these claims being attributable to paperwork inaccuracies or omissions, suppliers are placed in the position of potentially having to remove denied mobility devices from beneficiaries’ homes when the medical necessity may be genuine and subsequently proven on appeal. Most beneficiaries have genuine needs for their PMD and most appeals of denials are eventually overturned.
Beneficiaries should not be burdened with the uncertainty of the pre-payment review phase or denied their mobility independence while CMS develops and implements an untested, prior authorization process. Nor should beneficiaries, often living on limited fixed incomes, be placed in a position of paying their deductible and 20 percent copayment only to be at risk for having the device repossessed if the claim is denied for any reason.
In phase two of the project, CMS will move to a newly developed “prior authorization” program in the seven states three to nine months after the implementation of the project. The expense of developing an entirely new process and disrupting beneficiaries’ lives in the process is not justifiable and could be averted if CMS moved directly to an effective prior authorization process with opportunity for input from Congress, the public and the mobility device industry.
Does Medicare have to recreate the wheel for such a program? We think not! There are many effective examples in use by private insurers and other government programs. Rather than build a new process, we see no rationale for not adopting or adapting the well-established and highly successful process for prior authorization that is now in use by 49 of the nation’s State Medicaid programs, as well as by Medicare Managed Care Plans. Moreover, Medicare can do more to help physicians with templates and the capacity for electronic submissions to make more accurate and efficient the medical necessity documentation process to ensure Medicare beneficiaries’ timely access to needed mobility equipment.
Alexandra Bennewith
Director of Government Relations
United Spinal Association
Further Reading: Homecare Providers and Consumer Advocates Urge Congress to Stop Ineffective Medicare Payment Review Process for Mobility Equipment
