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House Lawmakers To CMS: Scrap Home Health Prior Authorization Demo Plan

Published by Inside Health Policy
Michelle M. Stein
May 26, 2016

A bipartisan group of 116 House lawmakers is asking CMS to scrap the idea of launching a home health prior authorization initiative after the agency signaled interest in such a demonstration earlier this year. Echoing the concerns of home health agencies and some beneficiary advocates, the lawmakers say the demonstration as laid out in a Paperwork Reduction Act notice is too broad and would impede beneficiaries' access to care.

“We ask you to withdraw the proposed demonstration for prior authorization of home health services in order to avoid health risks to patients, delays or disruptions in patient care and unnecessary restrictions on patient access to home health services,” say the letter, spearheaded by Reps. Tom Price (R-GA) and James McGovern (D-MA).

In a Paperwork Reduction Act notice, CMS expressed interest in subjecting home health claims in five “high risk fraud states” -- Florida, Texas, Illinois, Michigan and Massachusetts -- to prior authorization. The lawmakers say that under the demonstration, CMS would have to review more than 900,000 claims each year before beneficiaries could receive care, which they say would “will effectively delay and deny home health coverage for countless Medicare beneficiaries.” The lawmakers are concerned the demonstration would interfere with the patient-doctor relationship, cause longer and most costly hospital stays, and possibly contribute to higher hospital readmission rates.

The agency previously told Inside Health Policy the notice was simply a first step toward setting up such a demonstration.

“The Paperwork Reduction Act (PRA) notice in the Federal Register is an exercise to provide communication about prior authorization activities if they are approved for the future. The PRA notice is not an announcement of a prior authorization program for home health services. The PRA notice is one of the steps in the process required for CMS to move in this direction, but not the vehicle CMS would use to announce any program and/or its specifics," CMS said.

The lawmakers say that the PRA notice is insufficient to put forward such a wide-reaching program, and a full notice an comment rulemaking process would be required.

The lawmakers also note that prior authorization has never been applied to post-acute care as part of fee-for-service Medicare. But CMS has said it planned to test whether prior authorization would work in Medicare Part B, noting existing prior authorization demonstrations have worked well and the agency was interested in exploring other areas whether prior authorization might be beneficial.

The lawmakers question CMS' authority to implement the demonstration.

“The authority cited in the rule for implementing the program gives the Secretary authority 'to develop or demonstrate improved methods for the investigation and prosecution of fraud in the provision of care or services under the health programs established by this chapter,'” the lawmakers say (emphasis theirs). “The proposal to screen every home health service through a prior authorization process for the five identified states, however, tests a method of screening and utilization management, not a method of prosecution of fraud.”

The lawmakers also say they are concerned about how much the demonstration would cost, as CMS has estimated it would cost more than a quarter of a million dollars, and say it's unclear if it would actually prevent fraud or the submission of faulty paperwork or claims.

Shantanu Agrawal, deputy administrator and director for the Center for Program Integrity at CMS, recently told lawmakers at a House Energy & Commerce oversight hearing that improper payments in Medicare fee-for-service are driven by documentation problems, not fraud, and for home health providers these payments are often due to a lack of coordination between the ordering physician and the home health agency.

Click here to see the original article on the Inside Health Policy website.

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