Home Health Leaders Commend Bipartisan Senators for Expressing Concerns with Medicare Home Health Prior Authorization Requirement

April 25, 2016
Contact: Emily Adler

Home Health Leaders Commend Bipartisan Senators for Expressing Concerns with Medicare Home Health Prior Authorization Requirement

Senators warn prior authorization demonstrations may restrict access to timely home health services for vulnerable Medicare beneficiaries

Washington, DC - The Partnership for Quality Home Healthcare – a coalition of home health providers dedicated to improving the integrity, quality, and efficiency of home healthcare for our nation's seniors – thanked a bipartisan group of lawmakers in the U.S. Senate including Senators Bill Nelson (D-FL), Debbie Stabenow (D-MI), Gary Peters (D-MI), Marco Rubio (R-FL), Richard Durbin (D-IL) and Mark Kirk (R-IL) for sending a letter to the Centers for Medicare & Medicaid Services (CMS) warning that the agency’s prior authorization demonstration for Medicare home health fails to adequately target bad actors and may restrict patient access to timely home health services.

The bipartisan Senators – who represent three of the states Medicare has proposed including in the demonstration – write, “If finalized, this proposal could delay the delivery of care and place already vulnerable patients at risk. Patients who would otherwise receive care at home may need to seek care in more costly settings or return to hospitals.”

The Partnership – and stakeholders across the home health community – have expressed deep concern regarding CMS’ proposal to require the prior authorization of Medicare home health services. In a comment letter to CMS the Partnership outlined a series of concerns in response to the prior authorization demonstration including:

  • Negative impact on patients: 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. Facing delays in access to home health, medically frail seniors would face the risk of medical crises and higher readmission rates.

  • Financial and administrative burdens: Prior authorization will lead to higher costs, as patients who would otherwise be served in their home would instead be referred to higher-cost settings or return to hospitals. Further, this policy would increase the administrative burden on physicians and home health agencies, who are already required to provide extensive documentation on patient eligibility.

  • Limited ability to reduce fraud and abuse: Prior authorization will not stop 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. Indeed, the only change that would result from this policy is that payment to bad actors will be delayed, not prevented.

  • No legal authority to impose prior authorization for Medicare home health: CMS does not have statutory authority to impose prior authorization for Medicare-covered services, as Congress has provided such authority solely for durable medical equipment (DME). The Federal Register notice appears to highlight the Agency’s lack of authority to impose prior authorization, and Agency representatives have publicly noted CMS does not have this authority.

“We commend these bipartisan lawmakers for urging CMS to consider the true impact of prior authorization on Medicare beneficiaries’ home healthcare,” said Keith Myers, Chairman of the Partnership. “While we applaud efforts to reduce fraud and abuse in the Medicare program, we instead encourage CMS to work in coordination with the home health community to develop targeted program integrity measures to identify and eliminate bad actors without delaying patient care or increasing taxpayer costs.”

To view the Senate letter, click here.

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