Revised Qualitative Research Protocols Advocates

Department of Health & Human Services

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop C3-01-24

Baltimore, Maryland 21244-1850

OFFICE OF FINANCIAL MANAGEMENT

Qualitative Research Protocols: Advocates

Evaluation of Medicare Prior Authorization of PMDs Demonstration

Charlene Harven

Nurse Consultant

Division of Medical Review and Education

Provider Compliance Group

Centers for Medicare & Medicaid Services

7500 Security Boulevard

Baltimore, MD 21244

7-31-2013

Table of Contents

INTRODUCTION 3

INTERVIEW PROTOCOL: ADVOCACY ORGANIZATIONS 5

About Your Organization 5

About the Demonstration 5

About Medicaid and Other Prior Authorization Processes 7

About Anti-Fraud Efforts 8

General Questions 8

Overall Impressions 10

CLOSING 11

INTRODUCTION

Note: The interviewee will have received a written project description and verbal explanation of the project during the recruiting call, followed by a written invitation with the date and time of the scheduled interview. The interviewer may vary the focus and level of detail of questioning to reflect the interviewees’ background, knowledge, and expertise.

Thank you for your time today. As you may know, the Centers for Medicare & Medicaid Services (CMS) has engaged Provider Resources, Inc. (PRI) to evaluate the Medicare Prior Authorization (PA) of Power Mobility Devices (PMDs) Demonstration. As a part this evaluation, we are talking to those involved with and/or affected by the prior authorization process for PMDs. Today, we are specifically interested in learning more about your involvement in and experience with this Demonstration.

While you may have already seen a description of the Demonstration and PRI’s role as the evaluator, would you like me to briefly summarize them for you?

[If yes, say:]

The Medicare Prior Authorization of Power Mobility Devices Demonstration is a three-year demonstration that began in September 2012 and focuses on preventing fraud, waste and abuse while helping ensure the sustainability of the Medicare Trust Funds and protecting beneficiaries who utilize the Medicare program. CMS has contracted with PRI to evaluate the Demonstration through both quantitative and qualitative research and analysis, which includes quarterly interviews with key stakeholders.

Before we begin, I would like to read the following disclosure statement to you:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1235. The time required to complete this information collection is estimated to average [initial interview: 90 minutes OR follow-up interview: 120 minutes] including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

As previously mentioned we are soliciting input from a range of different types of individuals and appreciate your perspective on these issues. These interviews typically take an hour to an hour-and-a-half. We encourage you (and your staff) to be candid: your honest opinions and comments will be extremely helpful for the purpose of this research.  For note taking purposes, we would like your permission to record this interview to ensure that we have an accurate record of your comments and feedback.  Recordings and interview notes will not be shared with CMS or anyone outside of the immediate research team, and your privacy will be maintained to the extent provided by law.  The recordings will remain PRI’s property and will be destroyed following completion of our study. Do we have your permission to record this call?

[If yes, begin recording. If no, make sure the note taker knows this and is prepared.]

We typically only share information with CMS in an aggregate form so we can be sure to get your candid opinion and so that CMS is unable to directly identify individuals or organizations. However, from time to time specific examples and/or comments that cannot be de-identified can be very helpful in bringing issues with policy implications to the forefront.  If we identify such an example or comment from our conversation today, we are asking for your permission to attribute it to your organization, and will only do so with your specific verbal consent.  However, if you have any privacy and/or confidentiality concerns, you may decline at this time and we will not report any of your comments to CMS except when aggregated with those from other organizations so that they are de-identified.

Should these circumstances occur, do we have your permission or would you like to opt out of any attributable reporting?

[Specific interview topics will vary depending on the stakeholder group, Demonstration year, and whether this is the subject’s initial or follow-up interview later on during the Demonstration.]

As an advocate, we would like to hear about your organization’s perspective on the Demonstration, how it has affected beneficiaries and their access to PMDs for which they are eligible under existing Medicare coverage guidelines, and what impact you believe it has had on the integrity of the Medicare program.

We appreciate your perspective on these issues and your opinions and comments will be extremely helpful for the purpose of this evaluation of the PMD Demonstration.

Do you have any general questions before we get started?

[Once any questions are answered or if there are no questions, continue to the Interview Protocol.]

INTERVIEW PROTOCOL: ADVOCACY ORGANIZATIONS

In order to comprehensively measure the impact and effects of the Demonstration on beneficiaries, this interview guide is designed to cover a wide variety of different organizations with disparate levels of knowledge about the Demonstration. We have modified our questions based on our current knowledge of your organization’s background and involvement with PMDs and PMD procurement; however, some questions may not apply to your particular organization’s activities or advocacy priorities. We ask for your patience and understanding as we progress through our discussion today, and we will try our best to tailor our questions to keep our discussion relevant to your advocacy efforts as we learn more about your policy agenda, strategies, activities and outcomes related to ensuring beneficiary access to PMDs.

About Your Organization

We would like to start by learning a bit more about your work and your organization as a whole. We understand you advocate for [insert type of advocacy] and represent [national, state or regional organization].

• How many members or individuals do you serve?

• Overall membership characteristics (Demographics, percent covered by Medicare, stakeholder types in membership, etc.)?

• Proportion that qualifies for Medicare coverage of PMDs?

• Organizational structure (state or national level, most active chapters)?

• Your role in the organization?

• How and when does your organization become involved in issues about PMDs?

• Specific mobility-related diseases or injuries?

• As these diseases or injuries change over time, how are PMD needs and utilization affected? Does this differ for Medicare beneficiaries?

• Broadly, does your organization have a legislative policy agenda and, if so, how does it relate to the Demonstration?

• Do you track any Medicare policies that affect your membership?

• How do you hear about members’ policy concerns?

• How long does it take on average for you to hear about the effects of a new Medicare policy from your membership or those you serve?

• How are members involved with the leadership of organization?

• Do you try to educate your membership or those you serve about new Medicare policies?

• What common methods do you employ?

• How responsive is your membership/those you serve?

About the Demonstration

Next, we would like to talk specifically about the Demonstration and your organization’s involvement in monitoring its impact.

• How did you learn about the Demonstration?

• Did your organization participate in the development of the Demonstration?

• Did you and/or your colleagues attend any of the Open Door Forums?

• Were they helpful?

• Did your organization author any position papers or submit public comments on the Demonstration?

• What is your overall impression of the Demonstration compared to other prior authorization processes for PMDs?

• Which do you think works best for patients and ensures that those who require PMDs receive them?

• How has the Demonstration affected your organization’s work related to Medicare beneficiaries eligible for PMDs?

• How has the Demonstration affected Medicare beneficiaries requiring PMDs, and their caregivers, in your state or coverage area?

• Has the Demonstration affected the ability of those requiring PMDs to receive them in a timely manner?

• Approximately how much time passes between a beneficiary’s visit to a practitioner and when they receive their PMD?

Has this changed since the Demonstration began? Please explain.

• What have beneficiaries’ experience been with the Demonstration’s expedited reviews?

• Has the Demonstration affected the likelihood of your membership/target population to seek a PMD? Please explain.

• Have you noticed any differences in the ability of Medicare beneficiaries to obtain a PMD in Demonstration states (CA, FL, IL, MI, NC, NY, TX) compared to non-Demonstration states?

• What feedback have you heard from beneficiaries about the Demonstration and their ability to obtain PMDs?

• How does this differ from beneficiaries in non-Demonstration states?

• Do you track feedback, and specifically, problem cases, over time? Can you share some representative examples with us?

• Do you generally receive feedback from a representative cross-section of your membership or target population?

• Are some people more vocal than others? Please describe.

• Have you heard of beneficiaries/practitioners/suppliers having to resubmit documentation?

• How often does this occur?

• What are the more common reasons for resubmissions?

• Does beneficiary experience with the Demonstration vary across demographic characteristics (e.g. gender, ethnicity, income, education level, level of literacy and communication, type of mobility impairment or disease condition, family or caregiver status)? Please describe.

About Medicaid and Other Prior Authorization Processes

While our evaluation focuses on the Demonstration’s impact on Medicare beneficiaries, we would like to get a sense of the experience of Medicaid beneficiaries who are PMD users and also those PMD users who are experiencing other PMD prior authorization processes.

• Can you tell us about PMD procurement for Medicaid enrollees in any of the Demonstration states in which your organization is engaged?

• How do their experiences differ between managed care and fee-for-service?

• How do dual-eligible beneficiaries experiences differ from others?

• How long does it take for patients to obtain prior authorization from Medicaid?

• How does this differ from other payers?

• If you can, please describe differences across payers and states.

• What is your overall impression of the Demonstration compared to other prior authorization processes for PMDs?

• Which works best to ensure that patients who are eligible for PMDs under each program receive them?

• Do insurers or does your organization offer or use templates for PMD documentation?

[If CMS has implemented a template] Have your heard any feedback about Medicare’s template for the Demonstration?

• What have you heard about experiences submitting electronic prior authorization documentation instead of paper-based processes?

• [If CMS has implemented electronic submissions] How has Medicare’s introduction of electronic prior authorization submissions affected beneficiaries’ ability to acquire a PMD?

About Anti-Fraud Efforts

Now, we would like to learn more about your understanding of anti-fraud activities as a whole and how they may be affecting PMD access and procurement.

• Given your work and what you have observed, what impact has the Demonstration had on fraud and improper payments?

• Do you think that the Demonstration discourages fraud and abuse of PMDs?

• Do you think that the Demonstration promotes the development of new methods to reduce fraud, waste, and abuse of PMDs?

• What other anti-fraud efforts would you say have an effect on PMD access? Please describe.

• Are they on the state or federal level?

• Which activities do you believe are the most effective in preventing fraud while minimizing their impact on patient care?

General Questions

Now we would like to talk about your relationships with other stakeholders.

• How would you describe your organization’s interactions with other stakeholders as related to PMDs?

• Beneficiaries and advocates?

• Medical practitioners?

• PMD suppliers?

• DME MACs and CMS?

• Other?

[Probe for stakeholder type that the respondent names using the following additional probes:]

• How have these relationships changed since the Demonstration began?

• Are any changes the result of the Demonstration?

• Have they been positive or negative changes?

• What are some examples of feedback of each of the stakeholder categories?

• Are other stakeholders responsive to advocate concerns?

• Which other advocacy organizations are key stakeholders in PMD access and procurement?

• Do you know if they are following the Demonstration?

• How would you characterize your relationships with these organizations as they relate to PMDs and the Demonstration?

• Who are the stakeholders that form their political base?

• How have you been working together on PMD issues and what were the results?

• Have there been changes in your relationships since the Demonstration?

• Would you mind sharing your contacts’ information with us?

• [If yes:] Can we use your name as a reference when contacting them?

• How responsive have other stakeholders been to the various issues your organization has raised about access to PMDs under the Demonstration?

Next, we would like to get a measure of the current political climate of mobility and access to PMDs by talking about other policies, which broadly affect beneficiaries needing PMDs.

• What other policies or policy development initiatives are currently affecting access to PMDs that you believe we should be aware of as evaluators of the Demonstration?

• How has competitive bidding (and its expansion) affected access to PMDs?

• How has this changed when coupled with the Demonstration?

• What other pressures do suppliers and practitioners face that would impact their ability to operate effectively within the Demonstration?

• Have there been any changes in auditing efforts, or major changes in Medicaid policy or payments (for instance mandating managed care), or other changes in the Demonstration states about which we should be aware?

• [If HR 4378 or a similar bill has been passed and implemented] How has the passage of HR 4378, the Ensuring Access to Quality Complex Rehabilitation Technology Act of 2012 (CRT), or a similar bill, and subsequent creation of a separate benefit category for CRT affected access to PMDs?

• Has it affected PMD supply and/or beneficiary demand? Please describe.

Overall Impressions

• What is your overall impression of the Demonstration?

• What, if any, best practices in prior authorization processes should CMS consider as it evaluates the Demonstration?

• Is there anything that you would change about the Demonstration to help ensure PMDs are only provided to beneficiaries who qualify for the benefit? Why?

• How would you compare the administrative burden between different insurers that have prior authorization for PMDs (or other DME)?

• Which prior authorization process works best for patients and ensures that patients who require PMDs receive them and in a timely manner?

• Have you observed any unintended consequences resulting from the Demonstration? Please describe.

• What would you recommend CMS do differently in order to limit their impact?

[Continue to the closing.]

CLOSING

Before we end, do you have any additional thoughts or comments about the Demonstration that you would like to share with us, including any issues we may not have covered?

[Once any questions are answered/discussed or if there are no questions, continue below.]

Again, thank you very much for participating in this discussion today. We greatly appreciate your time and look forward to speaking with you again.