As CMS began a demonstration project to require prior authorization for Medicare coverage of power mobility devices (PMD), such as power-operated wheelchairs or scooters, the Senate Special Committee on Aging heard testimony from CMS, contractors and suppliers about the demonstration and CMS’ implementation. The prior authorization demonstration began on September 1, 2012, in seven states: California, Florida, Illinois, Michigan, New York, North Carolina and Texas. Some of these sites also have been the focus of escalated efforts to combat fraud, particularly with respect to home health and durable medical equipment (DME) services. According to one witness, nearly 50 percent of all Medicare claims for PMD come from these seven states.
Under the demonstration, suppliers must submit a request for authorization to the DME Medicare Administrative contractor (MAC) before furnishing any PMD to a Medicare beneficiary. The contractor will have ten days to review the request, after which it will either “affirm,” authorize the DME requested, or “non-affirm,” refuse authorization. The MAC is expected to provide a detailed description of the reasons that the requirements for coverage were not met.
The physician or supplier may resubmit the request an unlimited number of times; the MAC will try to review the resubmissions within 20 days. However, there is no appeal process for “non-affirms.” On receipt of a “non-affirm”, the supplier or physician also has the option to furnish the PMD and submit a claim. The MAC will approve or deny according to the usual process. Denial of the claim may be appealed.
Beginning December 1, 2012, a supplier who submits a claim without requesting prior authorization will be paid only 75 percent of the scheduled fee. The payment reduction is not subject to appeal. No reduction will be made to payments to contract suppliers in competitive bidding areas, however.
Health Professionals’ Concerns
A supplier of PMDs and a physician both testified before the committee about their concerns with PMD coverage and the demonstration. Michael Clark, chief Administrative Officer for The Scooter Store, testified that the MAC has denied every prior authorization request his company has submitted since the demonstration began. In particular, one authorization request was rejected because the physician failed to include the patient’s oxygen saturation rate on exertion, when the patient’s rate at rest was low enough that exertion could have endangered her health. Clark contended that the reviewer must not have had the medical background necessary to understand the risk. He also objected to CMS’ policy that physician letters of medical necessity are not considered part of the medical record for purposes of Medicare payment.
Dr. Jerome Epplin, a geriatric physician from rural Illinois, testified that many of the patients he sees who request PMDs are prompted to do so by direct-to-consumer advertisements, which lead to unrealistic expectations. Often, the PMD is not appropriate for the patient because he or she can preserve more functioning with other mobility devices such as a cane or walker. When patients are evaluated by physical therapists, a sales representative often accompanies them to the appointment and tries to influence the therapist’s completing the forms for authorization.
Dr. Eppelin hoped that the demonstration would help to improve the match between patient requests and medical appropriateness of PMDs. However, he believed the material explaining the demonstration was too long and unclear, and the lengthy form took 30 minutes to complete after a lengthy face-to-face assessment of the patient. Although the demonstration might deter fraud, it would not eliminate the possibility that the history given by the patient was influenced by PMD marketing.