Home Health & Hospice Week

Eliminating prior authorization doesn’t eliminate access issues.

Care problems ranging from delays to inability to access needed services are likely under the new pre-claim review demonstration for home health services.

The Centers for Medicare & Medicaid Services has made a big effort to pivot away from the prior authorization idea in its initial February proposal of this demo and recast it as “pre-claim review.” CMS changed the name of the demo to make clear that agencies don’t have to receive approval before initiating services, a CMS official staffer stressed in a June 14 forum about the demo.

Because HHAs don’t have to wait on approval, beneficiary access to home health services won’t be affected, the CMS official maintained in the forum.

Physicians Ready To Throw In The Towel On Home Health

But experts still expect access problems to arise from this demo. The Visiting Nurse Associations of America “believes this demonstration will jeopardize patients in the five impacted states who will not receive timely care,” the trade group says in a statement.

“More patients needing care will be turned away because their physicians can’t document for this constantly shifting target,” one home care industry veteran tells Eli.

Even if patients aren’t turned away altogether, parts of their care are likely to see delays. In the forum, physical therapist and consultant Dee Kornetti of Kornetti & Krafft Health Care Solutions warned CMS that at least some HHAs would hold off on providing expensive therapy services until they receive an approval of their pre-claim review.

The CMS official dismissed the idea, and said CMS would expect agencies to furnish care as usual. That delay of services won’t happen just with therapy, predicts finance expert Tom Boyd with Simione Healthcare Consultants in Rohnert Park, Calif. The general home care practice of “front-loading episode visits for the maximum benefit of the patient’s health and treatment will stop,” Boyd says. “The smart HHA will do as little service as possible until such time as they have received the pre-claim approval,” Boyd tells Eli. “The expensive therapies will be delayed or deferred until approval has been received, along with more than minimal nursing visits. Instead of 60 to 80 percent of the episode visits being done in the first 20 days of the 60-day episode, the pattern will reverse.”

The result: Expect to see more recertification episodes as patients finish out their treatment plans, Boyd says. That will result in higher Medicare expenditures.

Medicare spending under the demo will also increase as patients denied home care services due to confusing documentation standards return to hospitals and emergency rooms, predicts Washington, D.C.- based healthcare attorney Elizabeth Hogue. Barriers to home care should be decreased in light of Medicare’s emphasis on reducing hospitalizations, not increased, Hogue argues.