[Federal Register Volume 80, Number 135 (Wednesday, July 15, 2015)]
[Notices]
[Pages 41503-41505]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-17365]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-6057-N2]


Medicare Program; Extension of 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 an extension of the Medicare Prior 
Authorization for Power Mobility Devices (PMDs) demonstration.

DATES: This demonstration will now end on August 31, 2018.

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 demonstration based upon their history of 
having high levels of improper payments and incidents of fraud related 
to PMDs. On October 1, 2014, we expanded the demonstration to 12 
additional states (Pennsylvania, Ohio, Louisiana, Missouri, Washington, 
New Jersey, Maryland, Indiana, Kentucky, Georgia, Tennessee, and 
Arizona) that have high expenditures and improper payments for PMDs 
based on 2012 billing data.
    The objective of the demonstration is to develop improved methods 
for the investigation and prosecution of fraud in order to protect the 
Medicare Trust Funds from fraudulent actions and any resulting improper 
payments. The

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demonstration's extension will continue to provide 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 continue to share 
demonstration data within the agency, with our contractors, with state 
Medicaid agencies, 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. Our data analysis will include the 
following:
     Suppliers who no longer bill or have a significant 
decrease in billing during the demonstration.
     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 seven original demonstration states decreased after September 2012, 
indicating that physicians ordering and supplier billing practices have 
changed as a result of the demonstration. In addition, based on the 
preliminary data, 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

    This notice announces the extension of the Medicare PMDs 
demonstration for an additional 3 years, until August 31, 2018. 
Extending the demonstration allows us to continue developing improved 
methods to investigate and prosecute fraud in order to protect the 
Medicare Trust Funds from fraudulent actions and any resulting improper 
payments. This continuation will provide the agency with additional 
information through which the agency 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 continue to share demonstration data within the 
agency, with our contractors, with state Medicaid agencies, and with 
law enforcement partners for further analysis and investigation.
    This notice will serve as notification of the extended 
demonstration. In addition, we will publicize the extended 
demonstration through postings to our Web site and tweets.
    CMS or its agents will continue to conduct outreach and education 
including webinars, state meetings, and other educational sessions as 
appropriate. Updated information will be posted to the CMS Web site 
(http://go.cms.gov/PADemo). We will also continue to work to limit the 
impact on Medicare beneficiaries by educating the Medicare 
beneficiaries about their protections.
    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 any other clinical documentation 
that is necessary to determine medical necessity regardless of which 
entity is functioning as the submitter. The supplier must also complete 
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 subsequently 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 of 
Noncoverage (ABN) 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

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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 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 ABN apply.
     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: An applicable PMD claim is submitted without a 
prior authorization decision or 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 claim will be stopped and documentation will be requested to 
conduct medical review. The PMD claim is reviewed under normal medical 
review processing timeframes, and if approved, a 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, a 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 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 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

    This notice announces the extension of the Medicare PMDs 
Demonstration and does not impose any new information collection burden 
under the Paperwork Reduction Act of 1995. However, there is an 
information collection burden associated with the demonstration that is 
currently approved under OMB control number 0938-1169 which expires 
January 31, 2018.

IV. Regulatory Impact Statement

    This document announces an extension of the Medicare PMDs 
Demonstration. Therefore, there are no regulatory impact implications 
associated with this notice.

    Dated: July 1, 2015.
Andrew M. Slavitt,
Acting Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2015-17365 Filed 7-14-15; 8:45 am]
BILLING CODE 4120-01-P