Pre-Claim Review Demonstration
In 2016, the Centers for Medicare & Medicaid Services (CMS) introduced a Pre-Claim Review demonstration for home health agencies. Under this demonstration, home health agencies must receive approval from a CMS contractor to be reimbursed for providing physician prescribed home health services. As currently outlined by CMS, the Pre-Claim Review Demonstration allows seniors to start home health services, but requires the agency to submit applicable documentation which is not guaranteed to be approved. This process creates challenges for home health agencies to provide seamless, integrative, high quality skilled health care, which stands to threaten positive patient outcomes.
Pre-Claim Review is currently underway in Illinois and is scheduled to start on April 1 in Florida. Providers have noted care delays and denials and reported difficulties understanding the program requirements that requires additional and costly administrative resources better directed to patient care. To combat this problem, bipartisan members of Congress introduced the Pre-Claim Undermines Senior's Health (PUSH) Act, legislation to delay the Medicare demonstration for Pre-Claim Review of home health services for one year. The delay would allow Congress, CMS and home health stakeholders can work together to strengthen the program and improve education to ensure patient care is not compromised and individual beneficiaries are not unjustly denied coverage.
Face to Face Requirement
Under current Medicare policy, a patient needing home healthcare must have a documented face-to-face (F2F) encounter with a physician to certify his or her eligibility for services. The intent is to ensure patients are receiving care in the appropriate setting, but overly complicated and burdensome regulatory requirements result in unintended consequences like care delays or complete denial of skilled home healthcare services.
Data show tens of thousands of claims have been denied for care that is medically necessary and appropriate. While many of these claims are overturned on appeal, the initial denials make it difficult for home healthcare agencies to provide continued, uninterrupted care.
Legislation is being developed by leaders in Congress that would streamline the existing face-to-face documentation rules to reduce the paper work burden on physicians and home health agencies and inappropriate care denials. The legislation would allow for home health agencies to prepare documents for physician review and eliminate duplicative documentation for beneficiaries who have been discharged from a hospital or a post-acute care facility.
Data show the cost of providing Medicare home health to patients in rural areas is 24 percent higher per patient episode compared to patients in non-rural areas due to increased transportation costs, making it difficult to balance costs with already low Medicare reimbursement. Recognizing the increased costs associated with delivering care to remote locations, Medicare currently provides a 3 percent reimbursement safeguard for services furnished in rural areas. This 3 percent add-on is set to expire on December 31, 2017.
Medicare home health patients in rural settings are on average older than the general Medicare population and more likely to be dually eligible for Medicare, therefore continued access to home health services is critically important. Recent data found that there are more than 600,000 Medicare beneficiaries utilizing home health services in nearly 2,000 rural counties nationwide.
The Partnership is asking Congress to extend this valuable rural safeguard to ensure home health patients living in America's rural communities can maintain access to skilled care at home.