Medicare Compliance & Reimbursement

Prior authorization not the only provision in CMS notice that may affect you.

Medicare’s proposal for home health prior authorization could have severe repercussions for you.

The agency’s Feb. 5 notice in the Federal Register also calls for an extension of data collection for the Centers for Medicare & Medicaid Services’ (CMS’) Medicare Probable Fraud Measurement Pilot.

That’s a CMS pilot launched in 2013 that collects “information from home health agencies, the referring physicians and Medicare beneficiaries selected in a national random sample of home health claims” to “establish a baseline estimate of probable fraud in payments for home health care services in the fee-for-service Medicare program,” according to the notice. The program also relies on “a summary of the service history of the HHA, the referring provider, and the beneficiary.”

End goal: The project aims “to estimate the percentage of total payments that are associated with probable fraud and the percentage of all claims that are associated with probable fraud for Medicare fee-for-service home health,” CMS notes.

CMS developed the methodology for the program in 2011, then developed the measurement tools for the pilot in 2012 and collaborated with government partners on the strategy for implementation, the HHS Office of Inspector General (OIG) noted in its Health Care Fraud And Abuse Control Program Report for 2014.

CMS has yet to issue its probable fraud statistics, although it had estimated a 2015 date for the figures at the program’s outset.

Pilot Burdens Weigh Heavily on Agencies

Multiple commenters on the notice pointed out the many flaws with the program during the comment period that ended April 5.

The biggest problem: “The Pilot is an unnecessary and duplicative data collection exercise,” said Leslie H. Kamil of Michigan Visiting Nurses in Ann Arbor in the agency’s comment letter. “CMS already has ample existing data to identify and target fraudulent home health agencies.”

Medicare Administrative Contractors (MACs) are already reviewing claims from every HHA nationwide for face-to-face compliance under the Probe & Educate review initiative, pointed out executives from UnityPoint Health in West Des Moines, Ia., in its comment letter. “Collecting data from home health agencies and referring physicians in a national random sample of home health claims duplicates work currently being asked of all HH MACs for investigation of face-to-face encounter accuracy,” UnityPoint contends. “These same claims could be used to establish the baseline data being referenced in the Pilot and ... home health agencies, referring physicians, and Medicare beneficiaries do not need to expend resources and time to provide any additional information. Using this data recognizes the work of the HH MACs to create such baseline and subsequent trend data.”

The duplicative pilot is “masquerading as a fraud prevention program,” criticized Jan Usset, Director of Allina Health Home Health in St. Paul, Minn. “Does the perceived need for this pilot suggest the existing auditing/monitoring system by CMS (ADRs, CERTs, RAC, Focused Audits, Probe, etc.) is inadequate?” Usset asked in her comment letter. “Does CMS truly need to create another quality layer to duplicate programs that already exist to monitor for fraud and abuse?”

Overly broad: “I am incensed that CMS is going to take statistical data and determine a ‘probable fraud percentage,’” said a Florida commenter. “As a home care provider that follows the rules, sends in clinical records, spends administrative dollars on education and mitigation of potential fraud and abuse, this is yet another indication that our professional services are not valued.”

CMS should be targeting fraudulent home care providers by using easily accessed existing data sources such as fee-for-service claims, urged Sharon Jones, CEO of Southcoast Visiting Nurse Association in Fairhaven, Mass., in the VNA’s comment letter.

“Our industry is taking more than its share of oversight, punitive actions, and bad press because of a small cohort of providers,” said the Florida commenter. “It’s time for CMS to become more aggressive with those agencies that do not follow the most basic directives.”

Beware generalization: The probable fraud pilot holds another danger for HHAs, warned Chrissy Buteas of the Home Care and Hospice Association of NJ in the trade group’s comment letter. “Conducting this measurement pilot would appear to be a precursor for extrapolation to determine the scope or magnitude of Medicare home health fraud and abuse,” Buteas points out.

Beyond agencies’ control: Like F2F, data collection from non-HHA sources such as physicians and patients could lead to major inaccuracies, Buteas cautioned. “Concerns arise if data collection would be expected from physicians and beneficiaries who may not be forthcoming with information and therefore could negatively affect the audit results,” she said.

“CMS currently has the ability to collect documentation, data and claims information for home health beneficiary services and request as much additional documentation as deemed necessary to evaluate the justification of payments,” Buteas said. “Implementing this probable fraud measurement pilot would seem to go far beyond the reasonable auditing procedures that agencies currently undergo.”

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