Home Health & Hospice Week

Home health and hospice providers have plenty of complaints about Medicare Advantage organizations, but MAOs have complaints themselves — about Medicare.

For one: The Centers for Medicare & Medicaid Services has proposed a 3.7 percent reimbursement rate update for MAOs in 2025, according to its Advance Notice released Jan. 31.

“The increase is roughly the average of the past nine years — but far less than the 8.5 percent increase the MA plans received in CY 2023,” notes LeadingAge on its website.

“It remains to be seen if MA plans not satisfied with the proposal will seek remedy from Congress, especially after 61 U.S. senators showed their support late last week in a letter to CMS Administrator Chiquita Brooks-LaSure,” LeadingAge adds. “It is likely this letter was sent in anticipation of this notice being released.”

Comments on the notice are due by March 1, CMS notes in a fact sheet. The agency will publish “the final Rate Announcement on or before April 1, 2024,” it adds.

Meanwhile, in its Interoperability and Prior Authori­zation Final Rule (CMS-0057-F) released last month, CMS addresses provider and patient complaints about MAOs delaying care with prolonged prior authorization processes.

Prior authorization “can sometimes be an obstacle to necessary patient care when providers must navigate complex and widely varying payer requirements or face long waits for prior authorization decisions,” CMS says in its fact sheet about the final rule.

“Beginning primarily in 2026, impacted payers … will be required to send prior authorization decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests for medical items and services,” CMS says. “For some payers, this new timeframe for standard requests cuts current decision timeframes in half.”

Plus: “The rule also requires all impacted payers to include a specific reason for denying a prior authorization request, which will help facilitate resubmission of the request or an appeal when needed,” CMS continues. And “finally, impacted payers will be required to publicly report prior authorization metrics.”

Some insurers have already preempted prior auth problems by eliminating it altogether for home health. Blue Cross Blue Shield of Massachusetts announced back in November that it would remove prior authorization requirements “for home care services for commercial members beginning January 1, 2024,” according to a release. “This means hospitalized members will not be required to get advance approval before being discharged to continue treatment at home,” the plan said.

“This change will eliminate 14,000 authorizations from the health care system, reduce administrative burden on clinicians, and help hospitals expedite discharges at a time when many are struggling with overcrowding,” the plan highlighted. “It will also reduce delays for members ready to transition their care from hospital to home,” it said.

“We know that prior authorization requirements can be an obstacle to access home care services — resulting in delayed discharges and hospital capacity issues,” Dr. Sandhya Rao, Blue Cross’ chief medical officer, said in the release. “Our goal is to simplify our members’ discharge path to home with services that meet their needs,” Rao stated. 

Note: The 186-page rate Advance Notice is at www.cms.gov/files/document/2025-advance-notice.pdf. The 231-page final rule is at www.govinfo.gov/content/pkg/FR-2024-02-08/ pdf/2024-00895.pdf.