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.
On March 31st, the Centers for Medicare & Medicaid Services stopped the planned implementation of a Pre-Claim Review Demonstration in Florida and paused the application of the demonstration program in Illinois for at least 30 days, where it was originally implemented in August 2016. The decision to halt the demonstration will allow CMS, the home health community and other stakeholders to work collaboratively to strengthen the program with policy alternatives and through proper education and training. Further, home health leaders are asking CMS to work with them to develop alternative, targeted reforms to reducing fraud and abuse without disrupting the care of vulnerable Medicare patients.
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.
New data show the cost of providing Medicare home health to patients in rural areas is 36 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. The average travel costs per rural home health episode are $229 versus an estimated $168 average for non-rural episodes.
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.
A new analysis of Medicare home health beneficiaries completed by The Moran Company underscores the vulnerability of the rural home health patient population who rely more heavily on home healthcare services than their urban counterparts.
In general, home health beneficiaries are older, living with more chronic conditions, in need of more assistance with daily activities and more likely to be living in poverty when compared to the total Medicare population. Rural home health patients also have higher prevalence of disability and poverty than home health patients residing in urban areas.
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.
Click below to read more about the rural safeguard: