Revised Qualitive Research Protocols-Practitioners

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: Practitioners

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: PRACTITIONERS 5

About Your Practice 5

Communication from CMS About the Demonstration 5

About the Prior Authorization Process 6

About Your Work with Suppliers 7

About Medicare Beneficiaries 8

About Other Practitioners 9

Overall Impressions 10

Impact on Fraud Investigations and Improper Payments 11

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 Provider Resources, Inc. (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 Provider Resources, Inc. 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 a practitioner, we would like to hear about your perspective on the Demonstration, how it has affected Medicare beneficiaries and their access to PMDs, 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: PRACTITIONERS

About Your Practice

I’d like to start by asking you a few questions about your practice and your patient population. I understand you are a [indicate specialty] and part of a [describe practice type and size].

• What are the general characteristics of your patient population (e.g. frail, elderly, disabled, etc.)?

• How many patients could benefit from using a PMD?

• Among them, what conditions and diseases are most prevalent (e.g. osteoarthrosis, multiple sclerosis, cerebrovascular disease, etc.)?

• Among them, what is the mix of payers mix? [Note if numbers or approximate or actual, if for individual interviewee or whole practice]

• What proportion are Medicare beneficiaries?

• At a high level, could you please describe how you determine if a patient is in need of a PMD?

Communication from CMS about the Demonstration

Please tell us about your experience in terms of how you came to understand the requirements of the Demonstration.

• How knowledgeable do you feel about the prior authorization process for obtaining Medicare PMDs?

• Do you feel that you understand the requirements to document beneficiary need for a PMD?

• Did you receive instructions or outreach from CMS or your DME MAC [name the DME MAC] that you recall?

  • Please describe.

• To what extent do you (and your staff) communicate with your DME MAC?

• Did you participate in any of the Medicare Open Door Forums?

• Were they helpful?

• Did you participate in any other trainings or instruction about the Demonstration or prior authorization processes for PMDs?

• Please describe.

• Were they helpful?

• What level of familiarity do other practitioners you know have with the Demonstration?

About the Prior Authorization Process

Please tell me about your overall experience to date with the Medicare prior authorization process for PMDs.

• What effects, if any, has the Demonstration had on your practice and/or ability to care for Medicare beneficiaries requiring PMDs?

• How often does your office get involved in prior authorization processes for PMDs?

• How many prior authorization requests were submitted for your Medicare patients during the past year?

• Of these requests, what is the distribution of affirmed and non-affirmed prior authorization letters?

• How many of the non-affirmed cases were resubmitted for prior authorization?

• How many resubmissions ultimately resulted in affirmed decisions?

  • Please describe why resubmissions are typically required and what the typical timeframe was from the original submission to the time of final affirmation for those beneficiaries.

• Do you assist suppliers with resubmissions of prior authorizations or when additional documentation is being requested?

• Please compare your current rate of resubmissions to your rate of appeals from before the Demonstration.

• Are certain PMD suppliers more likely to be involved in resubmissions?

• Which suppliers are they and what are the key factors that increase the likelihood of resubmissions?

• Who in your office completes the paperwork to support a PMD prior authorization request?

• Can you please describe your other staff members’ role(s) and responsibilities in the process?

• Do any of them have a clinical background?

• How has your experience with the process changed since the start of the Medicare Demonstration?

• How often does your practice file claims for the corresponding G-code (G9156) associated with patient evaluations for the prior authorization process?

• Do you have any best practices in place that help ensure that prior authorization requests are submitted with complete and accurate supporting documentation?

• Do you use a template for completing the supporting documentation?

• Who created the template?

• How does the template compare to the documentation requirements for the Demonstration?

• If you are comfortable doing so, could you please send us copies of the templates or any other checklists you use to aid in the prior authorization process?

• How long does it typically take to hear back from [name the DME MAC] following your submission of a prior authorization request?

• Has the length of time changed since the beginning of the Demonstration?

• Please think about your current process as compared to what was in place before the Demonstration. Which process (Medicare prior authorization as opposed to claims submission) have you found to be more effective in both ensuring patients get the benefits to which they are entitled and preventing Medicare fraud?

• Which process, if either, is more expedient?

• Which process, if either, leads to more Medicare beneficiaries getting medically appropriate PMDs for which they are eligible?

• Which process has been less of a burden on your practice?

[These next two questions are to be asked only once the respective changes are implemented.]

• How has the introduction of a Medicare template for PMD documentation impacted your practice? What, if any, refinements would you suggest to the template?

• What impact has CMS’ adoption of electronic submission processes had on your ability to get prior authorization submissions reviewed and notices of determination back in a timely and efficient manner?

• What, if any, challenges remain related to electronic submissions?

About Your Work with Suppliers

Now I would like to discuss your and your staff members’ relationships with PMD suppliers and the impact the Demonstration has had on your work and relationships with them. The following questions are aimed at understanding how you characterize the nature of your relationship with the PMD suppliers.

[Note: Some of these questions may already have been answered earlier in the interview. Do not repeat.]

• Considering the availability of different suppliers in your area, do you work with a wide range of these suppliers or a specific subset of them?

• How do you choose the PMD suppliers with whom you typically work?

• How many different PMD suppliers do you work with on a regular basis?

• Can you please name them?

• How would you describe your relationships with PMD suppliers? Are they typically good? Bad? Neutral?

• Have you found different PMD suppliers to be very different to work with?

• What have been key differences in working with various suppliers and what do you attribute these differences to?

• What is the process and typical method of interaction with PMD suppliers?

• How often do you submit prior authorization requests compared to how often the suppliers you work with submit prior authorization requests?

• How do suppliers typically contact you after you write a referral?

• Do they ever come in person? If so, when and why?

• What assistance and guidance (including forms) do suppliers offer you as part of the process?

• If you are comfortable doing so, could you please share copies of these materials with us?

• How has the nature of your working relationship with PMD suppliers changed since the beginning of the Demonstration (or in the past year)?

• Is it more or less difficult to work with suppliers than before the Demonstration? Why?

• What are the challenges working with PMD suppliers related to the Demonstration?

• What best practices do you have to overcome these challenges?

• How have suppliers changed the way they have been marketing to you or beneficiaries since the Demonstration began?

• How would you or your Medicare beneficiaries describe your experiences with marketing from suppliers or retailers?

• Have these experiences changed since Demonstration began?

About Medicare Beneficiaries

• How, if at all, has the Demonstration affected your relationship with your Medicare beneficiaries and their caregivers?

• Has the Demonstration affected your Medicare beneficiaries’ ability to get the PMDs for which they are eligible under the Medicare program?

• How has it affected their care and quality of life in both the short-term and long-term of their condition(s)?

• Has there been a change in either the number of or type of Medicare beneficiaries requesting PMDs since the Demonstration began (or in the past year)?

• How many requests from Medicare beneficiaries are for a replacement PMD rather than their first one?

• Do your Medicare beneficiaries tell you about their experiences in obtaining PMDs?

• Has there been a change in number of Medicare beneficiaries expressing concern about their ability to obtain a PMD since Demonstration began (or in the past year)?

• How does this compare to before the Demonstration began?

• What are the challenges to ensuring timely access to medically appropriate PMDs for which beneficiaries are eligible with Medicare?

• Do your non-Medicare patients share with you their experiences obtaining PMDs?

• How do their experiences differ from those of your Medicare patients since the Demonstration began?

• What are some typical examples of experiences with other insurers?

About Other Practitioners

Next, to the extent it is relevant, we would like to hear about your experience with other practitioners as it relates to the Demonstration, as well as what you hear from them about their experiences.

• To what extent do you communicate with other practitioners about the Demonstration?

• What do you hear about it, if anything, from them?

[If the interviewee operates a seating clinic, rehabilitation center, or is a member of a physical and rehabilitation medicine practice, ask:]

• Who refers patients to you for an assessment?

• What is the mix of specialties referring PMD patients to your practice?

• In your experience, which specialties refer to you most often?

• How would you describe your interactions with referring practitioners?

• To what extent do you coordinate documentation for a PA request?

• Do these practitioners see their patients following your assessment to confirm your recommendation?

• Are there other seating clinics or practitioners you recommend we speak to about the Demonstration?

[If a physician (other than a physiatrist) in private practice, ask:]

• How frequently do you refer patients to a seating clinic, physiatrist, or rehabilitation center for a full assessment once you believe you have a patient who could benefit from a PMD?

• After referring a patient out of your clinic for an assessment, how do you follow up with the patient and the organization or clinician to whom you referred the patient?

• Does the organization or clinician performing the assessment follow up with your office?

• Do you incorporate the assessment report into your prior authorization documentation and beneficiary’s medical record?

• Do you see the patient for another face-to-face visit after reviewing the assessment?

• [If yes:] How does this affect procurement of the PMD?

• [If no:] Why not?

• Is any follow up with the patient or other clinician/organization noted in your documentation for the prior authorization request?

Overall Impressions

• What is your overall impression of the Demonstration?

• Is there anything you would change about Demonstration or how/what information you submit?

• How does your experience with the Demonstration compare to prior authorization processes you have worked with for other insurers?

• How would you compare the administrative burden of the authorization process between the different insurers?

• Which of the processes do you think work best for patients and ensure that patients who require PMDs receive them in a timely manner while at the same time minimize potential fraud? Please describe them.

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

• If you believe any of them to be negative in nature, what would you recommend CMS do differently in order to limit them?

• What is your experience with various Medicare auditing agencies?

• What is the general process for a Medicare audit?

• What are the typical outcomes of a successful or unsuccessful audit?

• How much time does an audit take?

• How frequently does Medicare, compared to other payers, audit your practice?

How often has that been related to PMDs?

• During the auditing process, are you able to provide all the necessary information requested related to PMDs in a timely manner?

• What other Medicare policies or environmental factors that you have observed interact with the Demonstration and/or a Medicare beneficiary access to PMDs?

• Are there any other relevant Medicare policies (e.g. health care reform, capped rentals, etc.) or environmental factors we have not yet discussed?

[Probe for each policy and/or environmental factor that the respondent names using the following questions:]

• Which had the most impact?

• Do you generally view the impact as positive or negative?

• How might these other efforts/factors be affecting the Demonstration?

Impact on Fraud Investigations and Improper Payments

One of the goals of the Demonstration is to promote the development of improved methods for investing and prosecuting fraud.

• In your opinion, do you think the Demonstration has had an impact on reducing fraud in your state?

• Are there other actions you would recommend CMS take in its efforts to limit fraud and improper payments?

[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.

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