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Home Healthcare Partnership Asks CMS To Pause Pre-Claim Review Demo

Published by Inside Health Policy
Michelle M. Stein
August 3, 2016

The Partnership for Quality Home Healthcare is asking CMS to pause its home health pre-claim review demonstration program, which started in August in Illinois, and work with stakeholders on new ways to reduce improper home health pay through targeted reviews and refined eligibility determination documentation.

“The Partnership and the broader Medicare home health community are concerned about this program,” said Colin Roskey, executive vice president of the partnership, in a statement. “We want to work with CMS to find ways to reduce errors in filing claims. Physicians and other practitioners who order home health care want to do it correctly. We urge CMS to press the 'pause' button and find a better solution.”

CMS signaled in a paperwork reduction notice earlier this year that it was thinking about requiring prior authorization for home health claims in five “high risk fraud states” -- Florida, Texas, Illinois, Michigan and Massachusetts. Home health companies and some beneficiary advocates criticized the proposal, and a bipartisan group of 116 House lawmakers in late May asked CMS to scrap it. In June, CMS announced plans to test a revised version of the demonstration that would use a pre-claim review policy rather than prior authorization. Stakeholders said the pre-claim review demonstration was an improvement over the earlier prior authorization plan but were still concerned about the broad nature of the demonstration.

The partnership is disappointed that CMS is proceeding with the Aug. 1 implementation of the demonstration in Illinois, the group's statement says. The demonstration kicked off Aug. 3 in Illinois, and CMS says it will start no earlier than Oct. 1 in Florida and no earlier than Dec. 1 in Texas. Programs in Michigan and Massachusetts will not start until next year at the earliest.

“We will continue to work with lawmakers and CMS as we track, research and evaluate the impacts of the pre-claim review demonstration in Illinois so that we understand the consequences of the demonstration before it is advanced in other states,” said Roskey.

Roskey told Inside Health Policy the partnership wants to work with CMS on a targeted review approach during a pause in the demo, though CMS wouldn't necessarily need to target providers geographically.

Roskey said the partnership also would like to work with CMS on refining eligibility determination documentation during any pause in the demonstration.

CMS previously said that documentation problems cause the majority of improper payments in the home health sector, and home health providers in 2014 sued CMS over documentation requirements that were later changed by the agency. An industry insider said refining documentation is an ongoing process.

The partnership says home health leaders have warned CMS that the pre-claim review policies will lead to higher Medicare and patient costs, “as patients who would otherwise be served in their home may be referred to higher cost settings.” The industry insider said that the demonstration will make it materially easier for doctors to order nursing home care than home health care.

“Burdensome new policies that complicate and constrain access to home health could unnecessarily drive patients into higher cost settings as ordering physicians struggle to meet the demonstration's new requirements,” Roskey said in a statement.

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

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