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.


Home Health Leaders Applaud Introduction of Independence at Home Act

The Partnership commends U.S. Senators Edward J. Markey (D-Mass.), John Cornyn (R-Texas), Michael Bennet (D-Colo.) and Rob Portman (R-Ohio) for introducing the Independence at Home Act, which will convert the Independence at Home (IAH) demonstration into a permanent national Medicare program.

The legislation has been lauded across the home health community for bringing primary medical services to Medicare beneficiaries with chronic and debilitating conditions in the comfort of their own homes. The Partnership previously praised the Independence at Home program for saving an estimated $25 million in its first year, or an estimated $3,070 per beneficiary, underscoring the value of home health services for aging Americans.

The program enables doctors and caregivers to provide primary care services to those in need of care at home, thereby reducing the number of unnecessary emergency room visits and avoidable hospitalizations and readmissions, and their associated costs.

The bill provides beneficiaries access to quality home care, giving them better control of their health and putting families at ease, while lowering healthcare costs.  The Partnership thanks these lawmakers for recognizing the value of home-based care and urges the Congress to work with home health providers to develop additional programs to protect patient access to care in the home.

New Analysis Shows Role Home Health Plays in Reducing Readmissions

Last week the Alliance for Home Health Quality and Innovation released new data regarding the Centers for Medicare & Medicaid Services’ (CMS) Comprehensive Care for Joint Replacement (CJR) Model.

The data analysis, conducted by Dobson DaVanzo & Associates, comes just more than two months after CMS launched the bundled payment model for major joint replacements in 67 regions of the country.

The analysis looks at discharges between October 2011 and September 2014 for patients from the hospital to various post-acute care (PAC) settings who underwent major joint replacement without major complication or comorbidity. It found that by sending patients to home health as opposed to a facility based setting, hospitals can lower the cost of the episode payment by $5,000 and reduce the risk of patients returning to the hospital.

Across all (PAC) settings, eight percent of episodes contained a readmission, but that number drops to an average of five percent for patients who received home health after their hospital stay. This is compared to readmission rates of 12 to 15 percent for patients receiving rehabilitation in facility-based settings.

As hospitals across the country begin implementing the new CJR payment model, this new data demonstrates that home health is a key component to reducing overall costs and bettering patient outcomes.

Honor Veterans by Protecting Access to Care

As Memorial Day approaches, the brave service men and women who fought so loyally for our country are in our minds and hearts. We show utmost appreciation for their sacrifices that have kept our country safe and free.

Memorial-DayEvery day, home health agencies across the country strive to improve care and quality of life for our beloved veterans, and this Memorial Day, we hope to continue providing all those affected veterans with their rightful access to quality care in their preferred setting.

Millions of American seniors – including those who served our country – rely on Medicare home health to remain in their home as they age.  To protect these noble veterans’ access to effective and efficient home healthcare, the Partnership is asking lawmakers to help prevent prior authorization requirements for home health, a process which would delay access to physician-prescribed home healthcare and increase costs for beneficiaries, the Medicare program and taxpayers.

Prior authorization has the potential to deter the timely delivery of care by requiring physician-ordered services to be reviewed and approved prior to care initiation, increase costs to Medicare by delaying hospital discharges, and limit the ability to reduce fraud and abuse.

To protect the well-being of veterans, and other seniors who depend upon access to care, we must raise awareness about the harms prior authorization can cause to the home health patients. We encourage everyone to support us in our journey to guarantee the health and happiness of American veterans by contacting their lawmakers to urge support:

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Home Health Value Kit: The Human, Clinical and Fiscal Value of the Skilled Medicare Home Health Benefit

We are pleased to release a new Home Health Value Kit: a guide that provides comprehensive information on the value of the Medicare home health benefit. Home healthcare provides clinically advanced, cost effective post-acute and chronic care management in the setting patients desire most – their home. So it’s critical for lawmakers, their staff, and other stakeholders to understand the benefits it has for patients, taxpayers and the Medicare program. Continue reading for a quick look into the kit and the information it offers:


This kit contains thorough information regarding home healthcare, from details about what home health care is, who receives it, information about the Partnership, and an outline of the human, clinical and fiscal value of the Medicare home healthcare benefit. You can also learn more about how you can support and empower the senior population through Bring The Vote Home, a national initiative designed to collect seniors’ opinions on a wide range of issues while simultaneously empowering both seniors and disabled Americans to engage fully in America’s electoral process.

Quick Facts

Human Value of Home Health

Home health patients are older, poorer and sicker than the Medicare population as a whole:

  • 4% of home health Medicare beneficiaries are older than 85
  • 2% live with five or more chronic conditions
  • 2% live at or below 200% of the Federal Poverty level

Clinical Value of Home Health

Patients in high quality home health and home-based care programs experience:

  • 26% fewer acute care hospitalizations
  • 59% fewer hospital bed days
  • A total of 19-30% savings in medical costs

Fiscal Value of Home Health

Skilled home healthcare is widely recognized as cost effective:

  • Medicare saves an average of $5,411 if home healthcare is the first post-acute setting utilized after a patient receives major joint replacement.
  • The average cost of care in a skilled nursing facility is $449 per day or $26,940 for a 60-day stay compared to $2,674 for a 60-day home health episode.

Want to learn more?

To view the kit in its entirety, click here.

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. 

Congress: Harmful Medicare Home Health Cuts Still Need Repeal

by former Congressman Billy Tauzin

billy-tauzinWinter break has officially ended and Congress is back in session gearing up for a busy 2016. As we inch closer to the election, both parties are lining up their priorities for the coming months.

On the docket this week is a vote on a budget reconciliation bill to repeal major parts of Affordable Care Act (ACA) including individual and employer mandates, taxes on high-cost healthcare plans known as the “Cadillac tax,” and the further expansion of Medicaid.

These are big ticket items, but not the only ACA policies that deserve thorough review and repeal by lawmakers. When the ACA was signed into law five years ago, so were significant Medicare cuts that put American senior care at great risk.

One such policy is a cut to Medicare funding for home health beneficiaries – a patient group that is documented as Medicare’s most vulnerable population.

In January 2014, the Centers for Medicare & Medicaid Services (CMS) authorized a 3.5 percent annual cut spanning the years 2014-2017 as part of the ACA. When all is said and done, this will amount to an unprecedented 14 percent cut to the Medicare home health benefit, threating access to care for millions of seniors and the jobs of thousands of home health professionals nationwide.

Further exacerbating the effects of a crippling cut is the fact that Medicare’s 3.5 million home health beneficiaries are older, sicker, poorer and are more likely to be female, a minority, and disabled than all other beneficiaries in the Medicare program combined. For example, data compiled by Avalere health found that 24 percent of home health patients are older than 85, compared to just 12 percent of the general Medicare population and 51 percent of home health patients live with five or more chronic conditions compared to just 24 percent of non-home health Medicare beneficiaries.

The steep cuts to home healthcare are also a hard hit to our nation’s rural communities. For many seniors living in rural areas, home healthcare is a vital service as the nearest hospital or medical center may be miles away. Without access to home health, these seniors may be forced to seek care in a more expensive institutional setting or choose to forgo necessary medical care all together.

As federal lawmakers prepare to vote on repealing pieces of the ACA, I ask them to remember the 3.5 million vulnerable seniors who rely on clinically advanced, cost-effective and patient preferred skilled home healthcare services. As we enter the third year of the harmful ACA home health cuts, it becomes even clearer that repeated cuts are simply unsustainable.

As we enter this New Year, I urge Congress to not solely repeal the ACA provisions currently included in the Senate-passed budget reconciliation package, but also the deep Medicare funding cuts that were included in the ACA too.

Billy Tauzin is former Chairman of the U.S. House Energy and Commerce Committee and senior counsel to the Partnership.

Bring the Vote Home Releases New Polling Data & Launches a New Website

One year out from the 2016 general elections, Bring The Vote Home has released the results of new polling data, which surveyed more than 2,000 registered voters over age 65.

This polling data revealed that American seniors want a candidate who will be an advocate for them on issues specific to those over 65, including healthcare. The poll also concluded that individual states have room to improve helping seniors cast their vote, with only four in 10 seniors indicating their state does a good job educating homebound seniors on how to register or obtain an absentee ballot.

For this reason, Bring The Vote Home has also launch a brand new website to offer seniors, disabled Americans, and their healthcare clinicians the information they need to register to vote and receive an absentee ballot!

Bring The Vote Home was originally developed so that Medicare home health patients (who are homebound) could fully participate in the democratic process. BTVH has expanded to offer additional resources, including information about their lawmakers’ views on home health and senior polling data on the views and opinions of American seniors.

Learn more about Bring The Vote Home by visiting the new website and from the infographic below:

Remember to Honor our Veterans

Today is Veterans Day, an important time for Americans to pause and consider the sacrifices that have been made by our country’s servicemen and women. Even against great odds, they have defended our way of life with valor and steadfast devotion.

Our appreciation for those who have served our country should go beyond just a single day – especially as they grow older. As veterans age, it’s crucial that we ensure our nation’s heroes are able to access quality, cost-efficient, and dignified care.

In 1972, the U.S. Department of Veterans Affairs (VA) established the Home Based Primary Care (HBPC) program, which provides primary care services to veterans in their homes.

Since HBPC was created, the program as reduced preventable emergency room visits and inpatient hospital days for veterans, resulting in a 24 percent decrease in total healthcare costs.

In 2014, the VA expanded veterans’ access to home healthcare through the Caregiver Support Program, allowing Caregiver Support Coordinators to assist family caregivers of veterans and providing services to aid in caring for their loved ones.

There’s no way to fully repay the debt we owe to those who have served our country, but we can help show our gratitude and give back by providing necessary care in the best possible setting as our veterans grow older. Home healthcare has clearly become one of the single most important aspects of care for veterans.

The home healthcare community celebrates Veteran’s Day every day as we dedicate ourselves to improving the lives of those who defended ours.

Happy National Family Caregivers Month

November is National Family Caregivers Month, which is a time to recognize the valuable role family caregivers play in the lives of America’s home health patients.  Many of Medicare’s home health patients are able to remain at home – and out of institutional settings – while receiving essential care services because of the collective support of home health professionals and their family caregivers.


Nearly 89% of seniors say they want to age in place, or live independently and remain in their own homes while receiving care. However, home health patients are more likely to live and they are also some of the poorest, sickest, and most vulnerable beneficiaries in the Medicare program, underscoring the critical importance of family caregivers.

Without family caregivers, it would be much more difficult to coordinate and provide the care our seniors need and deserve – and we want to say thank you!

Our friends at the Caregiver Action Network have many tools to help family caregivers.  There are many ways you can learn more about the role family caregivers play for home healthcare patients and how you can say thanks, including:

  1. Hear stories from family caregivers or submit your own
  2. Read through the Caregiver Action Network family caregiver toolbox
  3. Visit a forum to discuss issues caregivers deal with frequently