Success is in the Details

Date Published: March 17 2015

What have we learned from the seven original prior authorization states that we can apply to the 12 new expansion states?

Success is in the details.

What we are mainly discussing for these initial seven Prior Authorization States (TX, FL, CA, NY, IL, MI, NC) is what DOCUMENTATION lessons have been learned, because documentation drives your success or failure with Prior Authorization. These lessons break down into three categories:  1) What have referral sources learned (best documentation practices); 2) What information has the Centers for Medicare & Medicaid Services (CMS) gathered and shared? (information gleaned from monitoring); and 3) what have DME suppliers learned?  

From our expertise with face-to-face documentation we have found that DME suppliers and referral sources quickly learn from past omissions and are fast to adapt when specific objective criteria and standards are implemented and adhered to consistently.

Keep in mind that the Prior Authorization Demonstration (PA Demo) fundamentally will always be a somewhat subjective process no matter how many rules, regulations and criteria are implemented. You have humans conducting the patient evaluation; humans preparing the F2F documentation; and humans reviewing the documentation for CMS. That is an important point to keep in mind because CMS uses only objective criteria (error rate and $$ spent) to evaluate the effectiveness of their PA Demo, while it is mostly subjective analysis of the documentation and criteria applied which determines the objective data results upon which CMS relies to determine program effectiveness.

 As we all know, doctors are busy people and learning the ins and outs of changing Medicare requirements is simply not a high priority.  Couple this with the fact that many doctors, especially those in Family Practice, see patients somewhat infrequently whose condition necessitates the use of a Power Mobility Device, and that leaves many practitioners with a large educational and documentational void when it comes to DME, especially with power mobility.  This is not a new problem, however the PA Demo project has served to highlight specific issues with documentation from patient encounters the past two years from the initial seven states. Practitioners and DME suppliers in the 12 new expansion states should use these past experiences to glean and take advantage of the lessons learned and apply it in their practice.

Empowering physicians to effectively do their part from a documentation standpoint requires readily available information during the patient encounter illustrating what CMS is looking to have substantiated for the PMD.  CMS is looking for a narrative format from the physician that paints the picture of the patient’s condition and addresses specific data points.  Many non-affirm decisions come from a physician not properly documenting a data point that CMS is looking to have addressed during the patient encounter. A standardized online documentation tool with Medicare coverage criteria built into the program, such as, has a proven track record of obtaining more than 95% prior authorization affirmations.

If a physician simply conducts a routine physical exam without knowing what CMS is looking for the DME documentation is doomed to fail because routine physical exams do not cover all the criteria CMS is requiring be documented. For example, a routine physical exam may not ordinarily cover criteria such as the patient’s ability to maintain postural stability, which is necessary to address when prescribing a scooter. Or, a physician may routinely test and document upper extremity function and limitations, but they may not apply these quantitative findings to the next practical analysis of whether the upper extremity functional limits preclude self-propelling a manual chair.        

As a result we believe many physicians nationwide – as many as 60 percent – have stopped referring PMD. DME providers who have been proactive at approaching physicians with a solution to incorrect face-to-face documentation, such as, have succeeded in changing operational protocols and making the PA Demo a positive experience for both entities.

- Michael Blakey, President,

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