Medicare Compliance & Reimbursement

Beneficiaries of home healthcare could soon face access issues.

The Centers for Medicare & Medicaid Services (CMS) wants you to provide service even while awaiting MAC’s decision on Request for Anticipated Payment (RAP). The agency has decided to ignore forceful disapproval from within the home health industry and set up an incredibly short timeline for its implementation plan of the home health prior authorization demonstration.

The three-year demo, renamed the “Medicare Pre-Claim Review Demonstration for Home Health Service,” would start “no earlier than” Aug. 1, 2016 in Illinois, Oct. 1 in Florida, Dec. 1 in Texas, and Jan. 1, 2017 in Michigan and Massachusetts, CMS says in a notice released June 8 and scheduled for publication in the June 10 Federal Register.

CMS attempts to combat industry criticism that the demo will delay the onset of home care services by telling HHAs to start furnishing care before the Medicare Administrative Contractor renders a decision on a “pre-claim review request,” according to the notice. “The HHA provider should submit the Request for Anticipated Payment (RAP) before submitting the pre-claim review request and begin providing services while waiting for the decision from the MAC,” CMS instructs.

When an agency receives a MAC denial of its pre-claim review request, it could resubmit the request, or submit the claim to be denied and then file an appeal, CMS explains. CMS spends a significant portion of a fact sheet and question-and-answer set about the new demo justifying why the program won’t cause access problems.

“We are very disappointed that CMS is moving forward with this demonstration program,” says William Dombi, VP for law with the National Association for Home Care & Hospice (NAHCH). “While there are changes from the original proposal, serious concerns remain regarding the un-targeted approach and the impact of the project on care access and care cost,” Dombi says in a statement.

“The re-named pre-claim review program is better than originally suggested, but still very disappointing,” agrees Chicago-based regulatory consultant Rebecca Friedman Zuber.

“CMS has lost their mind,” insists reimbursement expert Tom Boyd with Simione Consultants in Rohnert Park, Calif. “The MACs do not have the structure and resources to handle this additional burden timely.”

The demo is “just something else to complicate the lives of those who work in the home health industry that is completely unnecessary,” laments Washington, D.C.-based healthcare attorney Elizabeth Hogue. “As if there aren’t enough checks on services provided already,” Hogue exclaims.

“Above all, CMS should be establishing clear, reasonable, and consistent claim documentation standards rather than instituting a pre-claim documentation review process,” Dombi maintains. “At this point, no one truly knows what is acceptable documentation.”

The Probe & Educate reviews are bearing that out, Friedman Zuber notes. “Our experience ... during the Probe and Educate Review of face-to-face documentation is revealing considerable inconsistency across reviewers and really obvious review mistakes,” Friedman Zuber tells Eli. Some review errors “are being overturned during the individualized telephone education sessions when providers point out that ‘missing’ documentation is, in fact, included in the submitted packet,” she notes.

Observers fear HHAs await the same mistakes under the pre-claim review demo. “This is going to be a mess,” predicts attorney Robert Markette Jr. with Hall Render in Indianapolis. CMS cites the 59 percent home health payment error rate reported by the HHS Office of Inspector General (OIG) in its notice.

“The reason the error rate continues to be so high is not because providers are incompetent or fraudulent, but because physicians are not documenting appropriately and reviewers are reviewing face-to-face documentation very critically,” Markette insists.

Potential Lawsuit in the Works

Background: Back in February, CMS published a very brief notice outlining its intention to launch a home health prior authorization demo. CMS received an avalanche of comment letters in response, with more than 325 parties submitting their feedback.

The vast majority of the commenters were critical, and often downright scathing, of the proposal. Home health agencies and their reps argued that the program would increase hospital readmissions, lengthen costly hospital stays, throw up barriers to cost-saving care, burden legitimate providers with little to no benefit to Medicare, and more.

Politicians went to bat for the industry. An April letter signed by six U.S. Senators urged CMS to reconsider the proposal. And in late May, members of the House of Representatives spoke out against the demo. A bipartisan group of 116 House members signed a letter urging CMS to withdraw the proposal altogether. The letter, spearheaded by Reps. Tom Price (R-Ga.) and Jim McGovern (D-Mass.), listed many of the same concerns HHAs voiced in their comment letters, including increased administrative burdens on HHAs and docs with no fraud-fighting benefit.

Now that CMS has shot down suggestions from HHAs and lawmakers, more serious measures may be necessary. NAHC is considering enlisting members of Congress to propose legislation to block the demo, or a lawsuit, Dombi tells Eli.

Note: See the notice at https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-13755.pdf.