While evidence already confirms that home healthcare is a cost effective care setting with positive clinical outcomes for patients, the Partnership is working to further improve quality and access for the patients we serve.
PRE-CLAIM REVIEW DEMONSTRATION
In 2016, the Centers for Medicare & Medicaid Services (CMS) introduced a Pre-Claim Review demonstration for home health agencies. Under this demonstration, home health agencies must receive approval from a CMS contractor to be reimbursed for providing physician prescribed home health services. As currently outlined by CMS, the Pre-Claim Review Demonstration allows seniors to start home health services, but requires the agency to submit applicable documentation which is not guaranteed to be approved. This process creates challenges for home health agencies to provide seamless, integrative, high quality skilled health care, which stands to threaten positive patient outcomes.
On March 31st, 2017, CMS stopped the planned implementation of a Pre-Claim Review Demonstration in Florida and paused the application of the demonstration program in Illinois for at least 30 days, where it was originally implemented in August 2016. The decision to halt the demonstration allowed CMS, the home health community and other stakeholders to work collaboratively to strengthen the program with policy alternatives and through proper education and training.
On May 29th, 2018, CMS announced that the Administration is seeking public input on a new proposal that includes the pre-claim review process for Medicare home health.
The revised pre-claim review demonstration will begin no earlier than Oct. 1st, 2018, and CMS has proposed implementing the new pre-claim review demonstration initially in Illinois, Ohio, North Carolina, Florida, and Texas.
HOME HEALTH GROUPINGS MODEL
In 2017, the Centers for Medicare & Medicaid Services' (CMS) Home Health Prospective Payment System (HHPPS) Proposed Rule for CY 2018 included the implementation of the Home Health Groupings Model (HHGM), a payment reform approach that would dramatically alter Medicare payment for skilled home health services. In the development of this payment approach, CMS did not solicit comment or seek industry input in the development of this proposed policy.
The HHGM would overhaul the current Medicare payment system in a non-budget neutral manner. Under HHGM, Medicare payments would be based on patient characteristics instead of care needs, and distributed based on location of providers rather than their quality of service. This would cause uneven payment distribution, as high-quality providers in certain areas could face disproportionate cuts. Furthermore, the geographic disparity would have the greatest effect on seniors living in rural, smaller areas.
On November 1, 2017, CMS announced its decision to not finalize the proposed HHGM in the HHPPS Final Rule for CY 2018. The Partnership looks forward to working collaboratively with CMS and the home health stakeholder community to address the significant flaws in the HHGM, and anticipates that CMS will do so in the year ahead.
FACE TO FACE REQUIREMENT
Under current Medicare policy, a patient needing home healthcare must have a documented face-to-face (F2F) encounter with a physician to certify his or her eligibility for services. The intent is to ensure patients are receiving care in the appropriate setting, but overly complicated and burdensome regulatory requirements result in unintended consequences like care delays or complete denial of skilled home healthcare services.
Data show tens of thousands of claims have been denied for care that is medically necessary and appropriate. While many of these claims are overturned on appeal, the initial denials make it difficult for home healthcare agencies to provide continued, uninterrupted care.
Legislation is being developed by leaders in Congress that would streamline the existing face-to-face documentation rules to reduce the paper work burden on physicians and home health agencies and inappropriate care denials. The legislation would allow for home health agencies to prepare documents for physician review and eliminate duplicative documentation for beneficiaries who have been discharged from a hospital or a post-acute care facility.