Home Health & Hospice Week

‘Scary,’ ‘appalled’ and ‘ridiculous’ are just a few of the harsh words industry used for proposal.

If home care industry veterans have anything to say about it, Medicare’s proposal for a prior authorization demonstration in five states will never get off the ground.

More than 325 parties filed comments in response to a Feb. 5 Federal Register notice proposing a demonstration in which its contractors would perform “prior authorization before processing claims for home health services in: Florida, Texas, Illinois, Michigan, and Massachusetts,” the Centers for Medicare & Medicaid Services said. “This demonstration would also follow and adopt prior authorization processes that currently exist in other health care programs.”

The commenters lambasted the proposal on numerous fronts:

Access: The proposed demo “in the rural areas will stop home care for the frail, elderly and dying patients I serve,” a commenter from Illinois told CMS. “Prior authorization is meant for medical services that have the luxury of planning ahead. Most home care referrals have not been planned medical care, but the result of an accident, or exacerbation of a chronic disease.”

“This will most certainly have a negative impact on patient care by extending the amount of time before services are rendered to patients who need to start therapy or nursing immediately following release from the hospital or rehab facility,” warned a Texas agency in its comment letter. The result: more hospital readmissions (see story, p. 115).

“To get prior authorization on home care patients is unrealistic,” an Illinois commenter told CMS. “Some patients need to be same day or next due to wounds, IVs, tube feedings, tracheostomies etc. It is impossible to get authorization that could take up to 10 days and have to see [the] patient within 24 hours of discharge from the hospital. Patients will not get services they need while waiting for prior approval.”

“This would be ridiculous to have a patient in need of services to wait,” declared one commenter.

Bene impact: “This sounds like just another way the government will delay and/or deny benefits to Medicare Beneficiaries, who have worked their entire lives paying into this system,” said a Florida commenter. “It scares me to think of how many people will suffer if this goes through.”

“Proposals like this play games with people’s lives,” warned another Florida commenter. “Delaying care for stroke, CHF and COPD sufferers will do irreparable harm.”

“Please take into consideration the patient before making a final ruling on this matter,” pleaded another Florida commenter. “I have been in Home Health Care since 1992 in several different positions. I have seen firsthand how the patient is the one that suffers with their care having to be held until authorization has been obtained.”

“This would be an incredible disservice to Medicare beneficiaries,” a Florida commenter insisted. “Not only will it delay needed care, it will have patients leaving hospitals and skilled nursing facilities waiting days to have their medication reconciled.”

Multiple beneficiaries wrote letters telling CMS to stop curbing their hard-earned benefits.

Burden: Already, “home health agencies are forced to employ extra in-house staff to meet paperwork and filing requirements,” said another Texas commenter. “Such programs drive home health agencies to be less about quality patient outcome and more about meeting paperwork and bureaucratic requirements.”

“As a successful HHA in Florida, it is becoming more and more difficult to focus on actual patient care, as we continue to attempt to meet the demands of CMS,” said one commenter. “Please take into consideration the additional administrative work that would be required.”

“Quit spending government money to produce more massive administrative costs,” chastised one Florida commenter.

“The number of extra staff it takes, both in the home health agency and physician office, to process these required documents mak[es] the existing minimal profitability even further strained,” noted a commenter self-described as “a registered nurse, owner and operator of one of the oldest home health agencies in fraud-laden Miami-Dade County.”

That burden is “forcing those of us who are legitimate providers to reconsider our position as we have become paper-pushers, teachers and collection agencies instead of patient caregivers and advocates,” according to the comment letter.

“This new requirement is taking nurses further from core patient care into more paperwork,” lamented a Massachusetts commenter. “The burden of processing a single Request … attaching all visit notes and HHA notes is time [and] labour consuming.

The resources to pay nurses decent wages is becoming consumed by clerical staff in the efforts of compliance with this regulation.”

“If CMS follows through on this pilot we would need to hire an additional part-time staff (20/week) to devote 100 percent of their time to this process,” said one Illinois agency. “With all the payment cuts and audits in process our cash flow is already poor,” it said.

Not the same: CMS offered its power wheelchair PA requirement as a comparison, but the need for that product is not as immediate as the need for home care, multiple commenters stressed. “People’s lives and need for home health cannot mimic the request for a piece of equipment,” said a Pennsylvania commenter. “Waiting 10 days for inexpensive service in the home gets folks out of costlier settings.”

Red tape: “CMS is not fully staffed with doctors to make real-time care decisions,” said the Texas commenter. “If home health agencies have a hard time getting a patient’s primary care physician to complete one face-to-face form in a timely manner, what confidence can we have that a more extensive process be done with greater efficiency and timeliness on such a large scale? And I believe each patient’s individual doctor who already has an entire health record including intimate knowledge of the patient and their needs is much better suited to make care decisions,” the letter said.

“How will CMS collect and ultimately respond to the hundreds if not thousands of requests it will receive on a daily basis?” asked an Illinois commenter. “Is CMS or are the intermediaries prepared to spend the time and money needed [to] implement a process and the appropriate tools to manage these requests?”

“What about the conditions of participation for home health?” asked another Illinois commenter. “Do we ignore the 48-hour rule to see a patient needing care?”

“This is the scariest thing I have read in a long time from CMS,” said a Texas commenter. “The debacle of face-to-face documentation, which got completely out of hand and cost good agencies thousands of dollars, makes me very concerned for this proposal.”

Physician impact: “Most physicians that are reputable and in demand do not have the time or the desire to accommodate the home health agency when asked to complete a document for which they are not reimbursed, nor will guarantee care for their patient,” said the Miami-Dade commenter. “Yet the entity that will ultimately not receive reimbursement due to improperly filled out documentation after providing the medically necessary services ordered remains the home health agency.”

Duplication: “CMS and the FI/MACs have always had the ability to review all services provided for all patient episodes (and still do) and all services that were deemed excessive and/or not warranted have been denied,” the Texas commenter noted.

“You already have fraud and abuse regulations in place that are working,” said a commenter. “Does CMS want to take over the medical decisions?” asked a Florida commenter. “A doctor writes orders ... and CMS will police the services?”

“This is yet another duplication of the already existing face-to-face requirement, which is another example of duplication of the 485 certification,” said the Pennsylvania commenter.

Lack of specificity: “The description of this demo is vague, without detail, without burden estimate,” noted a Pennsylvania commenter of the very brief Federal Register notice.

Hit hard: A number of Florida commenters protested the undue burden on their state, due to VBP, CJR and other programs. “Why Florida again,” one agency demanded.