Partnership Expresses Disappointment with Medicare Home Health “Pre-Claim Review” Demonstration

Washington, DC – The Partnership for Quality Home Healthcare – a coalition of home health providers dedicated to improving the integrity, quality, and efficiency of home healthcare for our nation’s seniors – today expressed disappointment with the revised home health prior authorization demonstration released today by the Centers for Medicare & Medicaid Services (CMS). Now called a “Pre-Claim Review” demonstration affecting seniors in five states over three years, the demonstration will impose still further documentation requirements on already burdened high quality home health agencies that could result in poor care transitions and still further confusion for seniors seeking care at home.

Home health leaders have previously warned that prior authorization policies will drive up costs to the Medicare program as patients would likely be sent to more expensive in-patient facilities, or potentially experience a hospital readmission while waiting alone at home for their prescribed post-acute care to begin. The Pre-Claim Review Demonstration takes a step forward to address this outcome by allowing seniors to start home health services while the agency submits applicable documentation, but it still creates new challenges for home health agencies in providing seamless, integrative high quality skilled health care, and thus could negatively impact the patient experience overall.

“We appreciate the steps CMS has taken to protect beneficiary access to care in the revised demonstration, however, much more needs to be done. We remain concerned that the demonstration does not go far enough to protect patients from potential harms inherent with pre-claim review, including confusion, delays and service interruptions in care for a vulnerable patient population” said Colin Roskey, Executive Vice President of the Partnership. “We are also concerned that CMS has not followed notice-and-comment standards for obtaining and responding to input from those immediately affected by the demonstration.”

Bipartisan lawmakers have also expressed concerns that home health prior authorization could cause dangerous delays in care for vulnerable home health patients. In a letter to CMS last month, 116 bipartisan House lawmakers wrote, “This demonstration project imposes costs on patients, providers and taxpayers. Delaying patient care while waiting for CMS to approve home health services may put patient health in jeopardy and cause patients to stay in the hospital longer than necessary.”

The mandatory pre-claim review demonstration paints all agencies in the affected states with a single brush. The Partnership instead recommends CMS pursue more targeted reforms that will strengthen program integrity without compromising the healthcare needs of patients. The Partnership has offered several proposals to address fraud, including targeting aberrant billing and utilization, ensuring sufficient qualifications and background checks, and identifying the isolated geographic areas which CMS data confirm are the ‘hot spots’ of fraud.

“We and our colleagues throughout the home healthcare community would welcome the opportunity to collaborate with CMS on the development and implementation of appropriate and targeted program integrity measures that fall within CMS’s authority and that would effectively identify and eradicate fraud and abuse,” the Partnership wrote in its comment letter to CMS.

Data compiled by Avalere Health reveal that Medicare home health beneficiaries are older, sicker, poorer and are more likely to be female, a minority, and disabled than all other beneficiaries in the Medicare program combined. Nationwide, 3.5 million homebound Medicare beneficiaries depend on the Medicare home health benefit to receive clinically advanced, cost effective and patient preferred care.