New Legislation Would Delay Pre-Claim One Year

A bill introduced in Congress this week would put a pause on the Pre-Claim Review Demonstration from the Centers for Medicare & Medicaid Services (CMS) with a one-year moratorium on the program.

The legislation, introduced by Representatives Tom Price (R-GA-6) and James McGovern (D-MA-2), comes after the home health industry has pushed back hard against the program, citing numerous problems in its roll out in Illinois. The bill, named the Pre-Claim Undermines Seniors’ Health (PUSH) Act, was introduced on September 28. The PUSH ACT is co-sponsored by Reps. Kenny Marchant (R-TX-24) and Mac Thornberry (R-TX-13).

The bill will delay the program one year after the enactment date within each of the five states. In addition, the bill requires the Secretary of Health and Human Services to provide a report to Congress within a year that includes a “comprehensive description and analysis” of the program in any state it was enacted before passage of the bill. The report must also include a description of the resources used by agencies, physicians and the Department of Health and Human Services; a description of alternative measures to identify fraud; and detailed data on the number of claims submissions and resubmissions, including data on approval and disapproval rates.

Earlier this month, CMS announced it would delay the implementation of the demonstration in Florida, Massachusetts, Michigan and Texas, though it did not say for how long. The program was originally anticipated to roll out in Florida as soon as October 1, and Texas by the end of the year. The demonstration requires home health agencies to submit their claims much earlier in the care process before getting paid for their services.

Rep. Price wrote to Congressional members about the demonstration, saying it “is creating barriers to care and forcing providers to incur significant unnecessary burdens to support an overly broad, untargeted and ineffective demonstration,” the National Association for Home Care & Hospice (NAHC) reported.

Those sentiments mirror what Illinois providers have said about the pre-claim model, calling their situation “desperate” and reporting significant administrative burdens that slow down care. At least one home health agency in Illinois has already closed its doors as a result of the pre-claim, according to NAHC.

“PCR began in Illinois on August 3, 2016 and almost immediately created chaos in the state’s home health agencies and their patients,” NAHC wrote in an update of the legislation. “Problems included a 60% to 80% non-affirmed rate, burdensome and time-consuming paperwork, an inefficient electronic system that cannot process the documentation, physician unfamiliarity with what is needed for PCR due to poor education from CMS and their contractor and considerable cash flow problems at agencies.”

Multiple industry groups have spoken out in favor of the legislation, including the Visiting Nurse Association of America (VNAA), which thanked Congressional members for introducing the bill in a statement.

“The disastrous rollout of the program in Illinois has clearly established that the current Pre-Claim Review demonstration should be discontinued before it seriously impacts patient health,” said Tracey Moorhead, CEO and president of VNAA. “We’ve already received multiple reports from providers across the state citing serious technical failures and improper claims denials, which have resulted in delays to the delivery of timely clinical services.”

The organization was also supportive of the measure to require a report of the pre-claim data.

Additionally, the Partnership for Quality Home Healthcare supports the bill.

“The legislation offers the relief the Medicare home health community has been seeking,” Colin Roskey, executive vice president of the Partnership, said in a statement. “We look forward to working with lawmakers in Congress to see that this bill is enacted and with CMS to improve the pre-claim review processes for the benefit of Medicare contractors, physicians, home health agencies and, most importantly, patients.”

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