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Price, McGovern Gather Support To Delay Home Health Pre-Claim Review Demo

Published by Inside Health Policy
Michelle Stein
September 29, 2016

Reps. Tom Price (R-GA) and Jim McGovern (D-MA) are urging colleagues to support legislation that would delay the home health pre-claim review demonstration for a year. CMS earlier this month paused expansion of the demonstration beyond Illinois, saying “additional education efforts will be helpful before expansion of the demonstration to other states.”

Earlier this year, CMS indicated in a Paperwork Reduction Act notice that it was interested in subjecting home health claims in five “high risk fraud states” -- Florida, Texas, Illinois, Michigan and Massachusetts -- to prior authorization. Home health companies and some beneficiary advocates criticized that proposal, and a bipartisan group of 116 House lawmakers in late May asked CMS to scrap it. CMS later announced it would implement a pre-claim review program rather than prior authorization. The agency said the pre-claim review program addressed lawmakers concerns.

Home health agencies said that a pre-claim review demonstration was an improvement over the prior authorization plan floated by the agency earlier in the year, but remained concerned.

The program went into effect in Illinois Aug. 3, but earlier this month CMS said it would hold off expanding the program to other states until it conducts more educational efforts focused on how to submit pre-claim review requests, documentation requirements, and “common reasons for non-affirmation.”

“CMS views these efforts as crucial to the long-term success of the demonstration for beneficiaries, providers, and the Medicare program. CMS will therefore take additional time prior to expanding to other states,” the agency says on its website.

The Center for Medicare Advocacy says that after correcting problems with uploading documents and technical glitches, two issues continue to surface in the on-going demonstration. One, CMA says, is with “tightly dictated standardized formatting that Medicare contractor requires in order to process pre-claim approvals.” The other is issues with face-to-face certification requirements. Home health providers have been raising concerns with face-to-face requirements for years.

“While requirements of this certification have been unclear since its implementation in 2011, the issues with face-to-face certifications became worse in 2015 (ironically, when the narrative requirement was dropped and the standards became more ambiguous). Pre-claim reviews are further highlighting the poorly designed, implemented, and inconsistently applied face-to-face requirements,” the Center for Medicare Advocacy says in an open letter to CMS.

The beneficiary advocates ask CMS to stop the demonstration before it causes more harm. Visiting Nurse Associations of America President and CEO Tracey Moorhead also said the disastrous rollout of the demonstration in Illinois clearly shows it should be discontinued before seriously impacting beneficiaries' health.

Price and McGovern note in a “Dear Colleague” letter that the demonstration could be re-initiated by CMS in other states in the future -- CMS says it will give at least 30 days notice before implementing the program in the other states, starting with Florida.

“After seven weeks of challenges in Illinois, CMS has plentiful information available to get to the root of any paperwork concerns and work with Congress on a more targeted corrective action plan,” Price and McGovern say.

The lawmakers seek support for their bill that would impose a one year moratorium on the project and require CMS to report to lawmakers on the impact of the project on beneficiaries, home health agencies, physicians, and Medicare spending. The report is also required to come up with a list of alternatives CMS could use to tackle Medicare fraud that doesn’t involve a nationwide implementation of pre-claim review for home health services, VNAA notes.

“It is important that Medicare take prudent and effective steps to eliminate fraud and protect Medicare for seniors and individuals with disabilities. However, this demonstration project is creating barriers to care and forcing providers to incur significant unnecessary burdens to support an overly broad, untargeted, and ineffective demonstration,” the Dear Colleague letter says.

The National Association for Home Care and Hospice, VNAA and the Partnership for Quality Home Healthcare support the bill, and partnership Executive Vice President Colin Roskey said the bill offers the relief the Medicare home health community has been looking for.

“We applaud Congressmen Price and McGovern for listening to the concerns of the Medicare home health community and leading efforts in Congress to delay the pre-claim review demonstration,” said Roskey. “We urge lawmakers to pass this bill to allow time for CMS and home health leaders to come together to study the consequences of this program and make necessary changes to ensure all stakeholders are prepared for its implementation so that patient care is not compromised.”

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

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