Home Health & Hospice Week

Increased bureaucracy will have no benefit, but major detriments.

Home care providers are making no bones about the fact that they are not fans of CMS’s prior authorization proposal for home health agencies.

Reminder: In the Feb. 5 Federal Register, the Centers for Medicare & Medicaid Services proposed a demonstration in which its contractors would perform “prior authorization before processing claims for home health services in: Florida, Texas, Illinois, Michigan, and Massachusetts. We would establish a prior authorization procedure that is similar to the Prior Authorization of Power Mobility Device (PMD) Demonstration,” CMS said. “This demonstration would also follow and adopt prior authorization processes that currently exist in other health care programs.”

Prior authorization will give rise to home care access problems, warned Lisa Harvey-McPherson, VP for government relations with Eastern Maine Healthcare System in Waterville, Maine, in a question-and-answer session following CMS Deputy Director Sean Cavanaugh’s presentation at the National Association for Home Care & Hospice March on Washington meeting April 4. Under the PMD demo CMS references in the Federal Register notice, contractors have 20 days to respond to a prior auth request. But in home care, delaying admission for even a few days is a big problem, Harvey- McPherson told Cavanaugh.

For example: Hospitals want same-day services for the patients undergoing lower joint replacements in CMS’s Comprehensive Care for Joint Replacement (CJR) model, Harvey-McPherson stressed. And if they don’t get it, the chance of rehospitalisation is likely to be much higher.

Prior auth is also a “meaningless addition” because it doesn’t convey prior approval for the services, added Sheila Guither with OSF Home Care Services in Bloomington, Ill., and president of the Illinois Homecare & Hospice Council’s Board of Directors.

Cross-purposes: Sometimes CMS’s policy goals of reducing Medicare costs and factors such as rehospitalizations “aren’t in synch” with CMS’s program integrity goals of reducing fraud, abuse, and payment errors, Cavanaugh acknowledged in response to Harvey-McPherson’s comment.

Costly Delays Inevitable

Attendees at the NAHC conference weren’t the only ones voicing their concern. CMS’s comment period on the prior auth demo closed April 5, and 54 comments were filed on the notice.

“Patients are coming out of the Hospital with a much higher acuity level than I have ever seen over the last 25 years,” said a representative from a Florida HHA serving 300 patients. “This means they need to be admitted to Home Care as soon as possible to minimize the risk of returning to the hospital,” the rep emphasized in a comment letter.

Through experience with Medicare Advantage, the agency knows that prior auth “definitely delays the start of services for patients due to the time it takes to obtain authorization, the additional man-power it takes to obtain the authorization, and the additional expense the agency is forced to put out to obtain, track, and manage the authorization process,” the rep told CMS.

CMS must hold up its end of the bargain for prior auth to work in home care, the agency said. “The response time must be immediate in obtaining pre-authorization or the patient is forced to go without care or the agency is forced to follow medical orders without securing payment,” the letter warned.

Another 14-year-old Florida agency with “a large volume of managed care” sees patients waiting “sometimes 5-7 days for care, which is causing some patients to seek urgent or emergency treatment when leaving an acute care setting and not getting service in a timely manner,” according to the agency’s comment letter.

The Home Health Conditions of Participation require care initiation within 48 hours of a referral or physician order, noted a commenter from Missouri. “This process measure was instituted due to the sharp improvement in outcomes when care is not delayed,” the commenter pointed out.

“I fail to see how this will save the Medicare fund any substantial amount,” the commenter continued. “It is guaranteeing that the timely delivery of care in the home health setting will be significantly impacted in a negative way.”

Conclusion: “Prior authorization policies will slow down our ability to serve patients, reduce patient access to essential home-based services, and add layers of bureaucratic paperwork to our administrative load, while not combatting or detecting additional fraud,” stressed five-location Colorado HHA Centura Health at Home in its comment letter.

“This initiative presents incredible administrative burden to agencies, but more than that fact, it will increase Medicare cost by decreasing access to care for our most vulnerable population at home,” says another commenter. “I would expect an uptick of ER and urgent care utilization based on the premise of this proposed project.”

“Pre-authorization will delay service, increase expenses for the provider, require the taxpayers’ money to be spent unnecessarily on redundant procedures … and take the patient care out of the hands of the patients’ physician whom knows the patient and their needs best,” one of the Florida agencies insisted in its letter.

Target Fraud-Fighting, Agencies Plead

“If this is a fraud prevention issue, then target the agencies where fraud has been noted and please allow the law-abiding agencies to continue to give good, quality, ethical service,” urged one of the Florida HHAs. “These broad sweeping mandates to the entire HH industry that target a small portion of providers are unfair to the population that needs our services and to the agencies that are working hard to save the Medicare program funds by providing good quality care at the least cost to the MC program.”

“The antiquated, wide-breadth approach to solving the fraud and abuse problem in the United States can’t be continued if the goal is better healthcare at effective costs,” argued the Missouri commenter.

“Adding more costly layers to the already strained system only offers those who perpetrate fraud another safe harbor to manipulate.”

“CMS clearly had a mission to decrease provider participation in the program, by hitting us yet again with a punitive program that hurts ALL providers, and is NOT targeted directly to those agencies that are not following rules and regulations,” another Florida provider said. “I strongly urge CMS to find a more specific mechanism to go after the fraud and abuse.”

Note: See the prior auth notice at www.gpo.gov/fdsys/pkg/FR-2016-02-05/pdf/2016-02277.pdf.