Demonstrations

On November 15, 2011 CMS announced three demonstration projects that aim to strengthen Medicare by eliminating fraud, waste, and abuse. Reductions in improper payments will help ensure the sustainability of the Medicare Trust Funds and protect beneficiaries who depend upon the Medicare program.

The CMS is pleased to announce that the Prior Authorization of Power Mobility Devices (PMDs) Demonstration and the Recovery Audit Prepayment Review Demonstration which were delayed from their initial January 1, 2012 start date are expected to begin in the summer of 2012. These demonstrations will begin after receipt of a paperwork reduction act (PRA) Office of Management and Budget (OMB) control number. The CMS posted a PRA notification for these demonstrations on February 3, 2012 - see the “Related Links Inside CMS” section below.  

The CMS significantly revised the Prior Authorization of PMDs demonstration in response to provider and supplier concerns. For more information on the adopted changes please visit the Prior Authorization of Power Mobility Devices (PMD) Demonstration website on the left side of this page.

Please continue to check this web site for updated information.

 

Demonstration Descriptions:

Prior Authorization of Power Mobility Devices (PMDs): Will implement a Prior Authorization process for scooters and power wheelchairs for all people with Medicare who reside in seven states with high populations of fraud- and error-prone providers (CA, IL, MI, NY, NC, FL and TX). This demonstration will help ensure that a beneficiary's medical condition warrants their medical equipment under existing coverage guidelines. Moreover, the program will assist in preserving a Medicare beneficiary's ability to receive quality products from accredited suppliers. This demonstration will begin for orders written on or after September 1, 2012. 

 

Contact: PAdemo@cms.hhs.gov

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Part A to Part B Rebilling: Allows hospitals to rebill for 90 percent of the Part B payment when a Part A inpatient short stay claim is denied as not reasonable and necessary due to the wrong setting (outpatient vs. inpatient). Currently, when outpatient services are billed as inpatient services, the entire claim is denied in full. This demonstration was limited to a 380 hospitals nationwide that volunteered to be part of the program. This demonstration allows hospitals to resubmit claims for 90 percent of the allowable Part B payment when a Medicare Administrative Contractor, Recovery Auditor, Comprehensive Error Rate Testing Contractor or the hospital finds that a Medicare patient met the requirements for Part B outpatient services but did not meet the requirements for a Part A inpatient stay. In addition, this demonstration is expected to lower the appeals rate which will protect the trust fund and reduce hospital burden. Beneficiaries will be held harmless with respect to changes in hospital coinsurance liability. For more information about this demostration, please visit the Part A to Part B Rebilling Demonstration website on the left side of this page. This demonstration began January 1, 2012.

Contact: ABRebillingDemo@cms.hhs.gov

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Recovery Audit Prepayment Review: Will allow Medicare Recovery Auditors (RACs) to review claims before they are paid to ensure that the provider complied with all Medicare payment rules. The RACs will conduct prepayment reviews on certain types of claims that historically result in high rates of improper payments. These reviews will focus on seven states with high populations of fraud- and error-prone providers (FL, CA, MI, TX, NY, LA, IL) and four states with high claims volumes of short inpatient hospital stays (PA, OH, NC, MO) for a total of 11 states. This demonstration will also help lower the error rate by preventing improper payments rather than the traditional "pay and chase" methods of looking for improper payments after they occur. This demonstration will begin on August 27, 2012. The Centers for Medicare & Medicaid Services (CMS) will hold a Special Open Door Forum on the Recovery Audit Prepayment Review Demonstration on August 9, 2012, from 2:00pm-4:00pm, ET. If you wish to participate, dial: 1-866-501-5502; Conference ID: 16834984. Full participation instructions and slides will be posted to this site when available.

Contact: RAC@cms.hhs.gov