[Federal Register Volume 79, Number 145 (Tuesday, July 29, 2014)]
[Notices]
[Pages 44038-44040]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2014-17805]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-6057-N]
Medicare Program; Expanded Medicare Prior Authorization for Power
Mobility Devices (PMDs) Demonstration
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Notice.
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SUMMARY: This notice announces the expansion of the Medicare Prior
Authorization for Power Mobility Devices (PMDs) Demonstration to 12
additional states.
DATES: This expanded demonstration begins on October 1, 2014.
FOR FURTHER INFORMATION CONTACT: Doris M. Jackson, (410) 786-4459.
Questions regarding the Medicare Prior Authorization for Power
Mobility Device Demonstration should be sent to [email protected].
SUPPLEMENTARY INFORMATION:
I. Background
Section 402(a)(1)(J) of the Social Security Amendments of 1967 (42
U.S.C. 1395b-1(a)(1)(J)), authorizes the Secretary to conduct
demonstrations designed to develop or demonstrate improved methods for
the investigation and prosecution of fraud in the provision of care or
services provided under the Medicare program. On September 1, 2012, we
implemented the Medicare Prior Authorization for Power Mobility Devices
(PMDs) Demonstration that would operate for a period of 3 years
(September 1, 2012 through August 31, 2015). The demonstration was
initially implemented in California, Florida, Illinois, Michigan, New
York, North Carolina, and Texas. These states were selected for the
demonstrations based upon their history of having high levels of
improper payments and incidents of fraud related to PMDs. The objective
of the demonstration is to develop improved methods for the
investigation and prosecution of fraud in order to protect the Medicare
Trust Fund from fraudulent actions and any resulting improper payments.
This demonstration is providing the agency with valuable data through
which the agency, working with its partners, can develop new avenues
for combating the submission of fraudulent claims to the Medicare
program for PMDs and improving methods for the investigation and
prosecution of PMD fraud. We will share demonstration data within the
agency, with our contractors, and with law enforcement partners for
further analysis and investigation. We believe that data evidencing
changes in physician ordering and supplier billing practices that
coincide with this demonstration could provide investigators and law
enforcement with important information for determining how and where to
focus their investigations concerning fraud in the provision of PMDs.
For instance, results from this demonstration could potentially
indicate collaboration between ordering physicians and suppliers in
submitting fraudulent claims for PMDs. This data could assist
investigators and law enforcement in targeting their investigations in
this area. Additionally, changes in billing practices that result from
this demonstration could provide specific leads for investigators and
law enforcement personnel. For instance, where a supplier that
frequently submitted claims prior to the demonstration stops submitting
claims during the demonstration, law enforcement may determine it
prudent to investigate that supplier.
Data we will analyze will include the following:
Suppliers who no longer bill or have a significant
decrease in billing.
Physicians/treating practitioners with a high volume of
submissions.
Codes that show a dramatic increase in use.
Based on preliminary data collected, spending per month on PMDs in the
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seven demonstration states decreased after September 2012, indicating
that physicians ordering and supplier billing practices have changed as
a result of the demonstration. In addition, spending per month on PMDs
decreased in the non-demonstration states. National suppliers have
adjusted their billing practices nationwide and appear to have
increased compliance with our policies in all locations, not just their
offices in the demonstration states.
II. Provisions of the Notice
Because of the initial success of the demonstration in reducing
spending on PMDs, we are expanding the demonstration to 12 additional
states (Pennsylvania, Ohio, Louisiana, Missouri, Washington, New
Jersey, Maryland, Indiana, Kentucky, Georgia, Tennessee, and Arizona)
which have high expenditures and improper payments for PMDs based on
2012 billing data. The 19 states selected for the demonstration, which
include the 7 current and 12 additional states account for 71 percent
of expenditures for PMDs in 2012. The remaining states and territories
would be the control group for the demonstration.
Prior to the start of the expanded demonstration, contractors and
the public will be notified about the expansion. This notice will serve
as notification in addition to Web site postings and tweets.
CMS or its agents will continue to conduct outreach and education
including webinars, in-state meetings, and other educational sessions
in the additional states as appropriate. Updated information will be
posted to the CMS Web site (http://go.cms.gov/PADemo). We will also
work to limit the impact on Medicare beneficiaries by educating the
Medicare beneficiaries about their protections. In addition,
physicians, treating practitioners, and suppliers who have recently
ordered a PMD for a beneficiary residing in a demonstration state will
be notified via letter about the expanded demonstration prior to the
start date of the demonstration.
Under the expanded demonstration, we will continue to follow the
policies and procedures that are currently in place for the
demonstration. In accordance with current demonstration policy, a
request for prior authorization and all relevant documentation to
support the medical necessity along with the written order for the
covered item must be submitted when one of the following Healthcare
Common Procedures Coding System (HCPCS) codes for a PMD is ordered:
Group 1 Power Operated Vehicles (K0800 through K0802 and
K0812).
All standard power wheelchairs (K0813 through K0829).
All Group 2 complex rehabilitative power wheelchairs (K0835
through K0843).
All Group 3 complex rehabilitative power wheelchairs without
power options (K0848 through K0855).
Pediatric power wheelchairs (K0890 and K0891).
Miscellaneous power wheelchairs (K0898).
Under this demonstration, a physician, treating practitioner or
supplier may submit the prior authorization request and all relevant
documentation to support Medicare coverage of the PMD item along with
the written order for the covered item to their Durable Medical
Equipment (DME) Medicare Administrative Contractor (MAC). The
physician, treating practitioner or supplier who submits the request is
referred to as the ``submitter.''
In order to be affirmed, the request for prior authorization must
meet all applicable rules, policies, and National Coverage
Determination (NCD)/Local Coverage Determination (LCD) requirements for
PMD claims. The LCD documentation requirement mandates that the
physician or treating practitioner shall complete the seven element
order, face-to-face encounter, and whatever other clinical
documentation that is necessary to determine medical necessity
regardless of which entity is functioning as the submitter. The
supplier completes the detailed product description (DPD) regardless of
which entity is functioning as the submitter.
After receipt of all relevant documentation, CMS or its agents will
make every effort to conduct a complex medical review and postmark the
notification of their decision with the prior authorization number
within 10 business days. Notification is provided to the physician/
treating practitioner, supplier, and the Medicare beneficiary for the
initial submission. If a subsequent prior authorization request is
submitted after a non-affirmative decision on a prior authorization
request, CMS or its agents will make every effort to conduct a review
and postmark the notification of decision with the prior authorization
number within 20 business days.
If the prior authorization request is not affirmed, and the claim
is submitted by the supplier, the claim will be denied. Medicare
beneficiaries may use existing appeal rights to contest claim denials.
Suppliers must issue an Advance Beneficiary Notice to the beneficiary
per CMS policy, prior to delivery of the item for the beneficiary to be
held financially liable when a Medicare payment denial is expected for
a PMD.
Submitters may also request expedited reviews in emergency
situations where a practitioner indicates clearly, with supporting
rationale, that the standard (routine) timeframe for a prior
authorization decision (10 days) could seriously jeopardize the
beneficiary's life or health. The expedited request must be accompanied
by the required supporting documentation for this request to be
considered complete thus commencing the 48-hour review. Inappropriate
expedited requests may be downgraded to standard requests. After
conducting an expedited review, CMS or its agents will communicate a
decision for the prior authorization request to the submitter within 48
hours of the complete submission.
The following explains the various prior authorization scenarios:
Scenario 1: A submitter sends a prior authorization
request to the DME MAC with appropriate documentation and all relevant
Medicare coverage and documentation requirements are met for the PMD.
The DME MAC then sends an affirmative prior authorization decision to
the physician or treating practitioner, supplier, and Medicare
beneficiary. The supplier submits the claim to the DME MAC and the
claim is linked to the prior authorization via the claims processing
system. Provided all requirements in the applicable NCD/LCD are met,
the claim is paid.
Scenario 2: A submitter sends a prior authorization
request, but all relevant Medicare coverage and documentation
requirements are not met for the PMD. The DME MAC sends a non-
affirmative prior authorization decision to the physician or treating
practitioner, supplier, and Medicare beneficiary advising them that
Medicare will not pay for the item. If the supplier delivers the PMD
and submits a claim with a non-affirmative prior authorization
decision, the DME MAC would deny the claim. The supplier and/or the
Medicare beneficiary would then have the Medicare denial for secondary
insurance purposes and would have full appeal rights. Existing
liability provisions with respect to delivery of a valid Advance
Beneficiary Notice of Noncoverage (ABN) apply.
If an applicable PMD claim is submitted without a prior
authorization decision it will be stopped and documentation will be
requested to conduct medical review. As with the
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initial states in the demonstration, after the first 3 months of the
expanded demonstration, we will assess a payment reduction in the new
states for claims that, after review, are deemed payable, but did not
first receive a prior authorization decision. As evidence of
compliance, the supplier must submit the prior authorization number on
the claim in order to not be subject to the 25-percent payment
reduction. The 25-percent payment reduction is non-transferrable to the
Medicare beneficiary and not subject to appeal. In the case of capped
rental items, the payment reduction will be applied to all claims in
the series.
The 25-percent reduction in the Medicare payment is for each
payable base claim not preceded by a prior authorization request except
in competitive bidding areas. If a competitive bid contract supplier
submits a payable claim for a Medicare beneficiary with a permanent
residence in a competitive bidding area that is included in the
supplier's contract, without first receiving a prior authorization
decision, that competitive bid contract supplier would receive the
applicable single payment amount under the competitive bid program, and
would not be subject to the 25 percent reduction. These suppliers must
still adhere to all other requirements of the demonstration.
Scenario 3: A submitter sends a prior authorization
request where documentation is incomplete. The DME MAC sends back the
prior authorization request to the submitter with an explanation about
what information is missing and notifies the physician or treating
practitioner, supplier, and Medicare beneficiary. The submitter may
resubmit the prior authorization request.
Scenario 4: The DME supplier fails to submit a prior
authorization request, but nonetheless delivers the item to the
Medicare beneficiary and submits the claim to the DME MAC for payment.
The PMD claim is reviewed under normal medical review processing
timeframes and if approved the 25-percent payment reduction would
apply.
++ If the claim is determined to be not medically necessary, or
insufficiently documented the claim will be denied. The supplier or
Medicare beneficiary can appeal the claim denial. If the claim, after
review, is deemed not payable, then all current Medicare beneficiary/
supplier liability policies and procedures and appeal rights remain in
effect.
++ If the claim is determined to be payable, it will be paid.
However, the 25-percent reduction in the Medicare payment will be
applied for failure to receive a prior authorization decision before
the submission of a claim. This payment reduction will not be applied
to competitive bidding program contract suppliers submitting claims for
Medicare beneficiaries who maintain a permanent residence in a
Competitive Bidding Area (CBA) according to the Common Working File
(CWF). These contract suppliers will continue to receive the applicable
single payment amount as determined in their contract. The 25-percent
payment reduction is non-transferrable to the Medicare beneficiary for
claims that are deemed payable. This payment reduction amount will
begin 3 months after the start of the expanded demonstration and is not
subject to appeal. In the case of capped rental items the payment
reduction will be applied to all claims in the series. After a claim is
submitted and processed, appeal rights are available if necessary.
If the prior authorization request is not affirmed, and the claim
is submitted by the supplier, the claim will be denied. Medicare
beneficiaries may use existing appeal rights to contest claim denials.
Suppliers must issue an ABN to the beneficiary per CMS policy, prior to
delivery of the item in order for the beneficiary to be held
financially liable when a Medicare payment denial is expected for a
PMD.
Additional information is available on the CMS Web site (http://go.cms.gov/PADemo).
III. Collection of Information Requirements
In the February 7, 2012 Federal Register (77 FR 6124) and the May
29, 2012 Federal Register (77 FR 31616), we published a 60-day and a
30-day notice, respectively, announcing and soliciting comments
concerning the information collection requirements associated with the
Medicare Prior Authorization for PMDs Demonstration implemented on
September 1, 2012. The information collection request for the
demonstration was approved under OMB control number 0938-1169.
Subsequent to the initial approval, we published an additional Federal
Register notice (79 FR 18913) announcing that we were seeking emergency
review and approval from OMB regarding the expansion of the
demonstration; specifically, we revised the information collection
request to account for the addition of 12 new states to the program.
The emergency revised information collection request was approved on
June 13, 2014, and is still approved under OMB control number 0938-1169
with an expiration date of December 31, 2014.
Dated: June 27, 2014.
Marilyn Tavenner,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2014-17805 Filed 7-28-14; 8:45 am]
BILLING CODE 4120-01-P