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.