CMS: Rethink Pre-Claim Review for Home Health Services

By Colin Roskey, Executive Vice President of Partnership for Quality Home HealthcareRoskey-colin

The Center for Medicare & Medicare Services recently proposed a pre-claim review demonstration for Medicare home health services, upon which approximately 3.5 million Medicare beneficiaries depend.

The Partnership is echoing concerns expressed by more than 120 bipartisan lawmakers to a previously proposed, and very similar, pre-authorization policy.  We are highly concerned the demonstration will result in unnecessary and unwarranted disruptions in seamless patient care, negatively affecting the weakest and sickest patient populations that depend on skilled home health care services to remain with their families and in their communities, not institutions.

Right now, the demonstration is set to start no earlier than August 1 in the state of Illinois, and shortly after, CMS will apply it to every claim made by every home health agency in Florida, Texas, Michigan and Massachusetts.

Why is this concerning?

  1. Medicare Administrative Contractors (MACs) are not fully prepared to manage the substantial increase in workload that will result from the pre-claim review demonstration. MAC staff will have to review 100 percent of all claims from all home health agencies in each state – a material new task requiring highly trained clinicians that can “turn around” each claim within 10 days.
  1. Home health agency (HHA) and physician workload and administrative costs will increase measurably.
  1. CMS has not armed physicians with the education and support needed to ensure they understand, and implement correctly, new pre-claim review policies and procedures.
  1. Pre-claim review policies will not appropriately prevent fraud and abuse.
  1. Home health stakeholders were given no opportunity to comment to CMS on the policies set forth in this demonstration project.

We continue to work with CMS and lawmakers in Congress to seek a solution that ensures that this demonstration is implemented in such a way that does not impede patient access to care, and that minimizes new burdens on home health agencies

We share CMS’s goal of eliminating fraud and abuse in the Medicare home health benefit, which we believe is a worthwhile and achievable goal.  We just don’t agree that pre-claim review policies will have the desired result nor will they target  bad actors who are currently abusing the system.  More targeted reforms are needed to protect patients as well as the quality and honest providers who deliver care to American seniors in their homes every day.


Five Reasons Prior Authorization Is Bad for Medicare Services

CMS is seeking comment on requiring prior authorization for Medicare home health, upon which approximately 3.5 million Medicare beneficiaries depend. Prior authorization means that a patient can’t receive the care her physician ordered unless and until a government official has reviewed that order (and a lot of other paperwork besides) and given it his blessing.

Learn why CMS should rescind this proposal:

  1. There is No Legal Authority for Prior Authorization for Medicare-Covered Services. CMS does not have authority to impose prior authorization for Medicare-covered services.
  2. It Will Have a Negative Impact on Patient Care and Outcomes. Prior authorization will impede the timely delivery of care because physician-ordered services will have to be reviewed and approved by a bureaucrat before care can be initiated. If delays were to occur in home health, medically frail seniors would face the risk of medical crises and higher readmission rates.
  3. It Will Impose Significant Financial and Administrative Burdens. Prior authorization will lead to higher costs, as patients that would otherwise be served in their home are instead referred to costlier settings, or return to hospitals.
  4. Prior Authorization Will Not Reduce Fraud and Abuse. Prior authorization will not stop those bad actors who are intent on defrauding the Medicare program. Instead, such criminals will submit false records to satisfy the prior authorization rules, just as they do for CMS’ other documentation requirements.
  5. Medical and Patient Advocates Want to be Part of the Solution! Home healthcare and other key stakeholders would welcome the opportunity to collaborate with CMS on the development and implementation of appropriate and targeted program integrity measures that fall within CMS’s authority and that would effectively identify and eradicate fraud and abuse without exposing patients to any risk or taxpayers to any increased cost.

You can urge CMS to set aside its prior authorization proposal by sharing this post on Twitter:

Click here to learn more about prior authorization. 

Preparing Home Health Patients for Natural Disasters

With the start of Hurricane season, we are reminded yet again of the importance of emergency preparedness for the home health sector. While hospitals and shelters help to protect many individuals in the event of a natural disaster, homebound patients often continue to rely on their home health providers to deliver the care they need before, during and after a disaster.

To help ensure patient safety and continuity of care throughout an emergency situation, home health agencies develop a preparation and response system for its staff to implement in the event that tragedy occurs.

Emergency planning starts the day a patient joins a home healthcare network. Most home healthcare providers have systems and practices in place that work to protection patients and their caregivers alike.

Once a patient enters the home health continuum, he or she is assigned a disaster classification code based on his or her condition and needs. These codes are updated regularly and allow the home health agency to prioritize care during emergencies.

For a natural disaster with warning, like a hurricane, home health agencies will start preparing patients in the days leading up to the storm. Each home health aide and manager will contact his or her patients to ensure that they will be safe during the storm, or relocated to their nearest family member or emergency contact’s home if needed.

If a patient must stay at home, their home health providers will make sure he or she has medication, medical equipment, food, and water to keep them comfortable and safe. In some cases, home health providers will even stay with patients throughout the storm or disaster. Providers will also notify the authorities about their patients and contact power companies in the event that a patient relies on electricity for a piece of medical equipment, such as a ventilator.   The goal is always to ensure that the patient’s healthcare is never at risk.

Once a disaster has hit, home health providers immediately start their recovery efforts. Within 24 hours, on-call nurses will attempt to visit all patients in the affected area, starting with the highest acuity patients. Home health providers will often work with the authorities to locate and care for their patients as quickly as possible.

Natural disasters are unpredictable and potentially devastating, particularly for home health patients with physical restrictions and health concerns. Home health professionals go above and beyond the call of duty to ensure that their patients remain healthy and safe, but real security is derived from the extensive emergency preparedness and planning that takes place before events even occur.

Letter to President Obama: Support Program Integrity Reform Instead of Across-the-Board Cuts and Higher Costs for Seniors

The Partnership for Quality Home Healthcare supports program integrity reforms in the Medicare program specifically targeting fraud and abuse to prevent these behaviors before they can occur.

As a member of the Fight Fraud First! coalition, the Partnership is working with others to ask policy makers to make every effort to eliminate waste, fraud and abuse from the Medicare program before cutting Medicare payments or asking beneficiaries who rely on these important services to shoulder more out-of-pocket costs.

In a letter sent to President Obama this week, Fight Fraud First! urged the Obama Administration to support program integrity reform instead of across-the-board cuts and increased costs for our nation’s vulnerable seniors. Read the letter below:


April 10, 2013

President Barack Obama

The White House

1600 Pennsylvania Avenue, NW

Washington, DC 20500

Dear President Obama,

As a coalition of groups representing millions of older Americans, persons with disabilities, minorities, veterans and healthcare providers – founded on the premise that eliminating waste, fraud and abuse in the Medicare and Medicaid programs should be a priority for lawmakers to reduce health care spending – we urge your Administration to support program integrity reform instead of across-the-board cuts and increased costs for our nation’s vulnerable seniors.

We respect that leaders in Washington have to make tough decisions when it comes to securing America’s financial future. While progress must be made, we ask that lawmakers strongly consider advancing policy solutions that generate savings through targeted efforts to prevent fraudulent activity and wasteful spending in the Medicare program, and increase successful programs designed to recoup government funds lost to fraud and abuse.

As you prepare to release your FY 2014 budget, we respectfully ask you to propose targeted solutions to prevent improper and fraudulent payments before they occur. Strengthening the current pay-and-chase system through program integrity reforms is a solution that makes sense for older adults, taxpayers and our nation’s health care delivery system.

Data suggest up to an estimated ten percent of Medicare funding is lost to waste, fraud, and abuse each year.1 Successful programs created by your Administration have addressed system weaknesses and yielded billions of dollars in Medicare savings. We believe even more can be done. Therefore, we ask that you support targeted approaches to combating fraud and abuse to protect our nation’s nearly 50 million Medicare beneficiaries.

Our organizations came together in the collective belief that correcting inefficiencies in the Medicare program is the most prudent approach to reducing federal spending within the Medicare program. Rather than turning to Medicare cuts or higher premiums or copayments that unfairly burden seniors, we urge the federal government to achieve savings by implementing policy solutions that stop waste, fraud, and abuse before it starts.

We encourage you to reject increased out-of-pocket costs or cuts to Medicare that would restrict beneficiary access or reduce benefits, and instead call for program integrity reforms that protect beneficiaries and save valuable taxpayer dollars.



American Autoimmune Related Diseases Association

Caregiver Action Network


National Association for Uniformed Services

National Grange

National Hispanic Council on Aging

Partnership for Quality Home Healthcare


Veterans Health Council

Vietnam Veterans of America

 1 U.S. Government Accountability Office. Medicare: Program Remains at High Risk Because of Continuing Management Challenges. GAO-11-430T. March 2, 2011.



CMMI Director Touts Value of Home Health

In a hearing before the Senate Finance Committee last week, CMS’ Center for Medicare and Medicaid Innovation (CMMI) Director, Dr. Richard Gilfillan, was the sole witness at a recent Senate Finance Committee hearing on ways to reform Medicare and Medicaid.  In his written testimony and during the hearing, Dr. Gilfillan sited the value of home healthcare in new delivery models for Medicare and Medicaid.

He further described how demonstration programs involving home health are working to improve outcomes and reduce Medicare costs.

In his written testimony, he states:

“Innovation Center initiatives include the Independence at Home Demonstration, created by the Affordable Care Act, which uses home-based primary care teams designed to improve health outcomes and reduce expenditures for Medicare beneficiaries with multiple chronic conditions. Under the Independence at Home Demonstration, selected primary care practices will provide home-based primary care to targeted chronically ill beneficiaries for a three-year period. Participating practices will make in-home visits tailored to an individual patient’s needs and preferences with the goal of keeping them from being hospitalized.”

Click here to see the video recording of the hearing.

Fight Fraud First! to Protect Medicare and Seniors

Who is Fight Fraud First!

Fight Fraud First! is a collaborative effort among advocates, seniors, persons with disabilities, military veterans, and minority communities. The coalition advocates that every effort should be taken to eliminate waste, fraud and abuse from the Medicare and Medicaid programs before any cuts are made to beneficiaries who rely on these important services.

Call to Action

In December of 2012, the coalition issued letters to House and Senate Leadership urging Congress to support program integrity reforms rather than across-the-board cuts or increasing seniors’ out-of-pocket costs. FFF! supports targeted reforms that stop improper and fraudulent payments before they occur.

Additionally, the coalition is urging concerned Americans to sign a petition to Congress with the same request: to eliminate the bad actors from Medicare who cause rampant waste, fraud and abuse in the system. The petition has more than 4,000 signers to date, but we need more to help make our voices heard in the halls of Congress.  Please visit the website and tell Congress to fight fraud first!

Progress in Home Healthcare

The Partnership and other leaders in the home care community have crafted a proposal entitled the Skilled Home Health and Integrity and Programs Savings (SHHIPS) Act that outlines program integrity reform and aims to stop waste, fraud and abuse by preventing it before taxpayer dollars ever fall into the wrong hands.

With targeted reforms, Congressional action and support from the healthcare community, we can eliminate fraud and protect our nation’s seniors.



Bipartisan Group of Senators Call for Stronger Efforts to Fight Fraud

In a press statement last week, Senators Max Baucus (D-MT), Tom Carper (D-DE), Tom Coburn (R-OK), and Orrin Hatch (R-UT) called for Medicare program integrity improvements.  Their statement was in response to a recent report by the Office of the Inspector General (OIG), which calls for more aggressive efforts to stop Medicare fraud and abuse before it occurs.

The bipartisan group of Senators called for stronger fraud detection processes within the Medicare Drug Integrity Contractor (MEDIC) program, which the OIG said is not doing enough to identify preventable cases of fraud.

Detecting Medicare fraud before it occurs is imperative to protecting beneficiaries, taxpayers and the Medicare program, which ensures access to healthcare for nearly 50 million Americans. Bipartisan support in the Senate for tougher policies is a significant step to strengthening fraud prevention efforts.

Action in the Home Health Community

A strong advocate for the prevention of Medicare fraud before it can occur, the Partnership has collaborated with other community leaders on a detailed proposal to strengthen the Medicare home health benefit by targeting waste, fraud and abuse within the system. The Skilled Home Healthcare Integrity and Program Savings (SHHIPS) proposal calls for such reforms as a more rigorous claims review process, stronger conditions of participation, and payment “guardrails” to prevent aberrant claims from being paid.

Program integrity reforms are key to reducing wasteful spending and protecting innocent beneficiaries from policy measures that could negatively impact senior care such as across-the-board cuts or increased copayments.

The Partnership is also a founding member of Fight Fraud First!, a collaborative effort of advocates for seniors, persons with disabilities, military veterans, and minority communities.  The FFF! Coalition advocates that every effort should be taken to achieve savings by eliminating Medicare and Medicaid waste, fraud and abuse before any funds are taken from Medicare beneficiaries or the benefits on which they depend. 

Medicare and Medicaid Fraud: a Targeted Problem in Need of a Targeted Solution

We recently had the opportunity to attend the Alliance for Health Reform briefing on healthcare fraud and prevention. It’s an important and timely topic for the home healthcare community. Our community recognizes that program integrity and payment reforms are needed to strengthen the Medicare and Medicaid programs and secure seniors’ access to quality healthcare services.

How Big is the Problem?

  • “Hundreds of billions of dollars in waste and fraud…” (President Obama speech to Joint Session of Congress, Sept. 9, 2009)
  • “These schemes steal as much as $100 billion a year from Medicare and Medicaid…” (Newt Gingrich and AARP CEO Barry Rand, Orlando Sentinel, Sept. 29, 2010)
  • “…Health care fraud and abuse (is) hundreds of billions per year…” (Harvard Professor Malcolm Sparrow, Senate Judiciary Committee, May 20, 2009)
  • One-third of all health care spending is fraud, waste and avoidable inefficiencies (Institute of Medicine [2011] and Thomson Reuters [2009])
  • Americans think 51 cents of every federal dollar spent is wasted (Gallup, September, 2011)

For additional information on the cost of health care fraud, please click here.

Fraud and Abuse is a Targeted Problem in Need of a Targeted Solution

The Partnership for Quality Home Healthcare is committed to working toward reforms that achieve significant savings and strengthen Medicare program integrity without harming seniors or cost-­efficient providers.

The Medicare Payment Advisory Commission (MedPAC) has identified 25 counties as having the highest prevalence of Medicare abuse in home healthcare:

MedPAC 25

The MedPAC data demonstrate that program integrity is a targeted problem. In response, the home healthcare community has developed bold reforms that offer a targeted solution.

Precedent: Medicare’s 10% Limit on Home Health Outlier Claims

In 2009, the home healthcare community proposed a Medicare reform limiting home healthcare outlier claims to 10% of a provider’s total reimbursement. This policy was adopted and has proven effective in achieving savings without harming seniors or cost-efficient providers.

Analysis of CMS’s recently released claims data for 2010 indicates that the Outlier Limit generated $853 million in savings in 2010 – equivalent to $11 billion in 10 year savings – without harming seniors or the vast majority of cost-effective providers who operate inside the national norms.

Our Proposal to Fight Healthcare Fraud

To fight fraud and strengthen program integrity, while protecting seniors who rely on home healthcare services, we propose payment reforms based on the Outlier Limit model:

  • Episode Limit: cap payment at a per-­provider average of 2.7 episodes per beneficiary (non-­rural) and 3.3 episodes per beneficiary (rural).
  • LUPA Limit: incorporate a minimum annual low utilization payment adjustment (LUPA) rate of 5% to all episodes payments.

To learn more about coordinated efforts to combat healthcare fraud by leading organizations representing America’s senior, disabled, minority and veteran populations, visit

Program Integrity Reforms Work

The Centers for Medicare and Medicaid Services (CMS) recently released data that backs up the Partnership’s position that program integrity reforms in Medicare can result in serious healthcare savings.

In 2009, the home healthcare community proposed a 10 percent cap on outlier payments to Medicare home healthcare providers.  The proposed policy was included in the Patient Protection and Affordable Care Act of 2010 and data has become available for the first time that proves the policy worked.  In fact, it resulted in even greater savings than the home healthcare community original projected.

In just one year, the outlier cap led to a 70 percent reduction in outlier payments, which generated $853 million in Medicare savings!

This new data goes to show that program integrity reforms work.  As Congress reconvenes this month, the Partnership will continue to work with lawmakers to advance more reforms that will strengthen the Medicare program, save valuable federal funding and, most importantly, help protect senior access to healthcare.