Home Health & Hospice Week

Don’t be surprised to see the program expand quickly.

Expect to wait weeks for Medicare approval of a home health episode under a newly proposed prior authorization demonstration.

In the Feb. 5 Federal Register, the Centers for Medicare & Medicaid Services proposes 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 says in the notice. “This demonstration would also follow and adopt prior authorization processes that currently exist in other health care programs such as TRICARE, certain state Medicaid programs, and in private insurance.”

On one hand: “The states targeted in the demonstration project have statistically proven high rates of fraud and abuse,” notes consultant Patti Zabell with McBee Associates. “A pre-authorization would help deter the fraudulent practices of many and at the same time could benefit the reputable agencies by preventing payment denials.”

Many HHAs would like to have a definitive yea or nay on whether Medicare would cover a patient before providing potentially unreimbursed services, observes attorney Robert Markette Jr. with Hall Render in Indianapolis.

On the other hand: A prior auth demo is bad news, says Washington, D.C.-based health care attorney Elizabeth Hogue. “Sometimes CMS and the MACs just get it wrong,” Hogue exclaims.

“This pilot sounds like a waste of time,” says billing expert M. Aaron Little with BKD in Springfield, Mo. “It’s disappointing to see Medicare piloting cumbersome processes that insurance companies and some Medicaid programs have in place.”

Plus: “Medicare has already piloted a prior authorization process in other health care segments and to my knowledge those pilots have not been successful,” Little tells Eli.

“Getting timely cooperation of the referring physician will be a miracle,” predicts industry veteran Tom Boyd with Simione Healthcare Consultants in Rohnert Park, Calif. Under the PMD prior auth demo CMS cites, suppliers must submit physician clinical records, face-to-face documentation, etc. with the prior auth request. Then the Medicare Administrative Contractor has 20 business days to respond to the request, according to CMS’s PMD demo website.

CMS is proposing five states for the demo now — four that have HEAT Medicare Fraud Strike Force teams operating in them, plus Massachusetts. That state is “likely on the list related to the recent crackdown on Medicaid agencies,” Boyd suspects (see related story, p. 54).

But don’t be surprised to see the demo spread quickly. With PMD prior auth, CMS initially launched the demo in five states in 2012, then expanded it to 12 additional states two years later. CMS also extended the end date for the PMD demo from 2015 to 2018.

HHAs Wait Anxiously For Demo Details

In the notice, CMS points out that the prior auth process is already in place for other payors.

The difference: But the process works very differently for other payors, Markette points out. For example, Indiana Medicaid pays per visit for home health services, so its prior auth process is focused on determining the number of visits it will cover.

Under Medicare, home health services are paid per episode. Does that mean prior auth reviewers will be denying requests based on homebound and medical necessity criteria, Markette wonders. Will reviewers look at OASIS scoring? Perhaps the number of therapy services will be under scrutiny, since they affect the case mix score and payment?

Outstanding questions exist related to timing of requests also, Markette points out. Do agencies complete an OASIS, then complete another one once the approval comes through three weeks later? When does the admission occur?

“Prior authorization doesn’t totally make sense under Medicare home health,” Markette maintains.

The wait time required for prior authorization also seems to work against Medicare’s stated objective of curbing rehospitalization rates, observers argue. Hospital-discharged patients waiting on an HHA admission could easily go back into the facility in the meantime.

The program also could run into operational bumps in the road, because the five states selected are served by three different HHH MACs, Boyd points out. “This will affect coordination of effort, uniformity of approach, processing time, statistical validity, and resulting findings,” he tells Eli. It would be better “to have one contractor or one MAC do the whole project.”

Prior Auth Burden Heavy

Even if the kinks are worked out, “the prior authorization for services is incredibly labor intensive,” warns consultant Julianne Haydel with Haydel Consulting Services. Haydel cites a client who had 500 patients, of which 100 were insurance — mostly Medicare Advantage. “There were three billers. One worked Medicare, one for managed care and the third split her time between both.”

Bottom line: “I do not see this working,” Haydel says. “For every 100 patients it will require a full-time person with experience, and that kind of money isn’t in the budget.”

Take action: HHAs and other interested parties may submit comments on the proposal until April 5, CMS notes in the notice. “Providers definitely need input regarding the criteria used for prior authorization,” Hogue urges. “Agencies and their representatives definitely need to comment on this demonstration and stay on top of its development.”

Note: See the notice at www.gpo.gov/fdsys/pkg/FR-2016-02-05/pdf/2016-02277.pdf. For an idea of what the prior auth program may hold, see the details of the PMD demo at www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/PADemo.html.