State and Local governments

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

Background Research Discussion Guide

Evaluation of Medicare Prior Authorization of PMDs Demonstration

HHSM-500-2012-00086C

Andrea Glasgow

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

Brief Description of the Demonstration and XXXX Role 3

DISCUSSION GUIDE 5

About your organization 5

General Background 6

Advocates 8

Practitioners 10

Suppliers 12

Government (Anti-Fraud) 13

Government (State Medicaid) 14

CLOSING 15

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, expertise, and whether they were interviewed in a previous year.

Thank you for your time today. As you know, the Centers for Medicare & Medicaid Services (CMS) has engaged XXXX to evaluate the Medicare Prior Authorization (PA) of Power Mobility Devices (PMDs) Demonstration. As a part this evaluation, we conduct background research to support the evaluation, including discussions with various stakeholders about PMDs, the Demonstration, relevant health policy issues, and other high level topics. Today, we are interested in discussing these topics with you and learning more about them from your perspective.

Brief Description of the Demonstration and XXXX’s Role

While you may have already seen a description of the Demonstration and XXXXs 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 XXXX 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-NEW. The time required to complete this information collection is estimated to average 90 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 stakeholders and we appreciate your perspective. These background research discussions typically take an hour and we encourage you to be candid: your honest opinions and comments will be extremely helpful for the purpose of this research and our overall evaluation of the Demonstration.  For note taking purposes, we would like to ask your permission to record this interview to ensure that we have an accurate record of your comments and feedback.  Recordings and interviews 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 XXXX 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?

Do you have any general questions before we get started?

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

DISCUSSION GUIDE

About your organization

We would like to start by learning more about your work and your organization as a whole. We understand you are [insert type of position held by interviewee] and represent [national, state or regional organization/agency].

Please tell us more about you and your organization’s roles and responsibilities related to PMDs.

General Background

• How would you describe the typical payer processes required for obtaining a PMD?

• How does the process of obtaining a PMD differ across payers?

• What, if any, are the significant issues Medicare beneficiaries face when obtaining a PMD?

• How would you compare the prior authorization processes of private payers compared to Medicare and Medicaid?

• Who are the major PMD stakeholders (e.g. practitioners, suppliers, advocates, government agencies, DME MACs)?

• Nationally?

• In your state or region?

• Have your relationships with these stakeholders changed since the Demonstration began?

• If so, how?

• What type of interactions do you have with other PMD stakeholders?

• Have your relationships with other stakeholders changed since the Demonstration began?

• What do you believe are the major PMD issues related to prior authorization processes of various payers?

  • Supplier-practitioner relations?

  • Supplier-beneficiary relations?

  • Practitioner-beneficiary relations?

  • Supplier-specific issues?

  • Practitioner-specific issues?

  • Beneficiary access?

  • Interactions between or among other stakeholders such as DME MACs and/or anti-fraud organizations or initiatives?

  • Other?

• How have the major issues related to PMD prior authorization programs changed over time?

• Do they vary by geography/region?

• How has CMS’ Demonstration affected any of these?

• In the last three years, what changes at the national or state level have affected how Medicare beneficiaries obtain PMDs (other than the Demonstration)?

• PMD market trends? Technological innovations? Medical best practices? Media coverage? Policy issues? Other?

• What issues do you think are likely to come up in the near future?

• Are there any specific documents, newsletters, blogs, or other key information sources you recommend we track throughout the Demonstration as we seek to remain informed about the PMD environment in your state or region?

• How familiar are you with CMS’ Prior Authorization of PMDs Demonstration?

• How did you learn about the Demonstration?

• Has the Demonstration affected Medicare beneficiaries’ ability to obtain PMDs for which they are eligible?

• How has the Demonstration affected other PMD stakeholders?

• Are there any other ways the Demonstration has affected the PMD environment?

• What is your overall opinion the Demonstration?

Next, we’d like to discuss the issue of fraud, waste, and abuse.

• To what extent is fraud, waste and abuse an issue with PMDs, both nationally and in your state/region?

• Has the extent to which this is a problem changed over the past few years?

• If you are comfortable sharing, what are some common fraud, waste, and abuse behaviors you have heard of related to PMDs in your region?

• Are there any PMD related anti-fraud initiatives active in your area?

• Any anti-fraud initiatives promoted by (or involving) Medicare?

• Anti-fraud initiatives promoted by (or involving) other payers?

• Anti-fraud initiatives promoted by (or involving) other government entities/agencies?

• Do you think that the Demonstration has had an effect on PMD-related fraudulent activity in your state or region?

• If so, how?

• What, if any other initiatives are Medicaid and other payers considering or involved in to help combat fraud?

• In your opinion, what is their motivation to get involved in these initiatives?

[Continue to the appropriate section for stakeholder group-specific questions.]

Advocates

You identified [reference issues identified in previous section] as major issues within PMD procurement and access. I would like to ask you a few more questions to better understand these issues from your perspective.

• How involved are you and your organization with issues relating to PMDs and the Demonstration?

• In which states or regions are you most active?

• [If not nationally active:] Why are you more active in some states and not others?

• Which other advocacy organizations are active in this area?

• Do you coordinate your work with any of them (or other non-advocacy groups)?

• [If yes] Which organizations and why?

• Have there been any recent changes in the advocacy network, such as new groups forming initiatives or collaborations on PMD-related issues?

• Have your members expressed any opinions about the Demonstration to you?

• If so, what are the most common issues?

• How does your organization keep track of opinions, feedback and/or questions about:

• PMD usage, access and/or procurement in general?

• Specific usage, access and/or procurement related to the Demonstration or Medicare beneficiaries in particular?

• From your advocacy perspective, how has the Demonstration affected beneficiaries’ access to PMDs?

• How has access changed since the Demonstration began?

• To what extent and how do advocates, or your collaborative organizations/committees, keep track of beneficiaries’ needs with regard to PMD usage or procurement?

• In your opinion, how has the Demonstration affected PMD-related fraudulent activity?

• Are you and your organization actively tracking the Demonstration?

• What are your organization’s thoughts on the Demonstration?

• Have these changed over time?

• Do you have any relevant databases or reports tracking challenges faced by Medicare beneficiaries related to obtaining PMDs that you can share with us?

• How would you describe advocates’ relationships with practitioners, suppliers and government agencies involved in PMD procurement and access?

• Do you have any suggestions for other advocacy organizations, practitioners or suppliers involved in procuring PMDs that we should contact as part of our evaluation?

• Would you be willing to share their contact information with us and allow us to use your name if we contact them?

[Continue to the closing.]

Practitioners

• How has the process of obtaining a PMD for Medicare beneficiaries changed for you or your colleagues in the past year?

• Are your patients who are eligible for a Medicare paid PMD able to acquire one in a timely and efficient manner?

• If not, what are some of the most common issues faced?

• How would you describe the relationship between practitioners and suppliers?

• What are the most common issues that affect the supplier-practitioner-patient relationship as it relates to prior authorization of PMDs?

• How often do your patients require or request a PMD?

• Does it differ by payer (specifically between Medicare, Medicaid and private payers)?

• Has there been a change in the number or type of patients who are requesting and/or receiving PMDs in the past year?

• If so, does it vary by payer type?

• What are the most significant differences between dealing with each of these payers when it comes to your patients requiring a PMD?

• Have there been any changes in the way your practice prescribes PMDs or how your practice is involved in the prior authorization process since Medicare’s Demonstration began?

• Does the Demonstration’s prior authorization process affect your ability to ensure that your patients who require and are eligible for PMDs receive them?

• Do you conduct the medical need assessments for those of your patients who require a PMD?

• Do you refer patients to licensed/certified medical professionals (LCMPs)?

• If not, why not?

• Are you a member of any professional group or organization that may have an opinion on the Demonstration?

• [If yes] Which one(s)?

• What is the group’s opinion on the Demonstration?

• How has it changed over time?

• Do you have any suggestions for other practitioners or organizations involved in procuring PMDs that we should contact as part of our evaluation?

• Would you be willing to share their contact information with us and allow us to use your name if we contact them?

[Continue to the closing.]

Suppliers

• How would you describe your and the overall market for PMD suppliers in your [region/state/target service area]?

• If you are familiar with Competitive Bidding Areas, how does this affect your and the overall market?

• Have there been any significant changes since the Demonstration began?

• [If yes] Please describe.

• Have suppliers faced increased or new challenges within the past year?

• [If yes] Please describe.

• How has the Demonstration impacted your business model and the way you interact with Medicare beneficiaries?

• Have there been any changes in the volume of PMD sales in the past year?

• Have there been any changes in the patient/customer pool requesting or receiving PMDs? (e.g. types of patients, insurance coverage variance, etc.)

• Has there been a change in the types of PMDs being sold?

• Has there been a shift towards customers paying more out-of-pocket than before the Demonstration?

• How have the relationships between practitioners, suppliers, and patients changed over the past 1 to 2 years?

• Are there any significant changes that are payer-specific?

• How has the Demonstration affected these relationships, if at all?

• Have there been any significant changes to the key suppliers in your area offering PMDs to Medicare beneficiaries?

• If so, do you have a sense of why these changes have occurred?

• What is your service area for PMDs?

• Have you used the Advanced Determination of Medicare Coverage?

• If so, how does this compare to the Demonstration?

• Do you have any suggestions for other suppliers, coalitions of suppliers, or other organizations involved in procuring PMDs that we should contact as part of our evaluation?

• Would you be willing to share their contact information with us and allow us to use your name if we contact them?

[Continue to the closing.]

Government (Anti-Fraud)

• What kind of Medicare anti-fraud activities are you involved with?

• Have there been any changes in the organizations that identify or correct PMD cases with fraud?

• Have you observed any changes in the nature or frequency of PMD cases involving fraud?

• Have certain stakeholders or organizations been more or less involved with PMD fraud, waste, and abuse?

• Can you provide any examples of ongoing initiatives, how they are being carried out, and their overall impact?

• Has the Demonstration itself had any effect on reducing fraudulent activities?

• Has it helped foster the development of novel anti-fraud efforts?

• How have Medicare anti-fraud initiatives changed over time?

• Have there been any new anti-fraud activities or strategies in the past year?

• [If yes] From where did the initiatives originate?

[Continue to the closing.]

Government (State Medicaid)

• Does your state’s Medicaid program have a prior authorization process for PMDs?

• When was it introduced?

• How is the process structured?

• Is it a stand alone or part of a larger DME prior authorization process?

• What are the goals of your program?

• Have you been able to achieve them?

• How has the volume of PMDs varied over time, and the most recent several years?

• Why?

• Have the types of PMD requested changed over time?

• Why?

• Has there been any change in the number of PMD claims paid over time?

• Why?

• What types of feedback have you received from your beneficiaries?

• Have you notice any changes in your state as a result of Medicare’s Prior Authorization of Power Mobility Devices Demonstration?

• How has Medicare impacted your processes?

• Did the Demonstration have any unintended consequences on your state? (i.e. consequences beyond its stated goals)

• Has your program changed either the general eligibility or prior authorization requirements for obtaining a PMD in the past year?

• Are there any recent or upcoming policy changes that will impact beneficiaries’ ability to acquire PMDs?

• Have you observed any changes in the way private payers provide PMDs to eligible beneficiaries?

• What are the ways your program combats fraud, waste, and abuse?

• Have you observed any changes in the nature or frequency of PMD cases involving fraud?

[Continue to the closing.]

CLOSING

Before we end, we have a few more questions:

• From your perspective, what are the pros and cons of the Demonstration?

• What, if any, feedback or best practices would you share with Medicare about the Demonstration?

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

• Are there any other people you recommend we should speak with as we continue our research and evaluation?

[If yes, ask for contact information and if we can reference them as an introduction to the new individuals]

[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 in the future.