CMS Prior Authorization Rule for Home Health Called into Question by Leading Industry Advocacy Group

WASHINGTON, D.C. (May 13, 2016)—The Partnership for Quality Home Healthcare—a coalition of home health providers dedicated to improving the integrity, quality, and efficiency of home health care for our nation’s seniors—recently expressed deep concern regarding the Centers for Medicare & Medicaid Services’ (CMS) proposal to require the prior authorization of Medicare home health services. If enacted as proposed, the proposal stands to delay access to services while also increasing costs to the Medicare program and taxpayers, and place burdensome requirements on providers.

The Medicare home health benefit provides vital health care services to a highly vulnerable and frail population; as such, requiring prior authorization will undoubtedly impede the timely delivery of care as physician ordered services must be reviewed and approved by CMS before care can be initiated. Other health care sectors that require prior authorization have documented care delays of up to 10 days.

“Home health patients are often at greatest risk during the transition from hospital to home,” stated Keith Myers, Chairman of the Partnership for Quality Home Healthcare. “For care to be delayed by several days opens up the possibility for a host of adverse events ranging from missed medication, to new infections, to poor management of chronic conditions. We urge CMS to recognize the potential negative patient consequences that will result from a prior authorization requirement and we urge the agency to not proceed with a prior authorization demonstration program for home health.”

Home health leaders further warn that prior authorization would 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 proposed demonstration program also stands to increase the administrative burden on physicians and home health agencies who are already required to provide extensive documentation on patient eligibility for home health care services.

Furthermore, the proposal as crafted does not stand to reduce the amount of fraud and abuse in the home health community, as CMS intends. The bad actors intent on committing fraud will continue to do so by submitting false records to satisfy the need for prior authorization, just as they do for CMS’ other documentation requirements, resulting in the delay, rather than prevention of fraud.

In addition to these policy concerns, home health leaders stress that CMS does not have the legal authority to implement this prior authorization demonstration.

Instead of implementing a policy that stands to negatively impact patient care, the home health community advocates for targeted reforms that will strengthen program integrity without compromising the health care needs of patients. The Partnership has been dedicated to this since its inception in 2010 and 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 stand ready to work with CMS and welcome the opportunity to collaborate on the development of targeted and sustainable reforms that eradicate fraud and abuse without compromising access to quality patient care for Medicare’s most vulnerable patient populations,” added Myers.

Skilled home health professionals serve one of the Medicare program’s most vulnerable patient groups. 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.

Click here to read the Partnership’s comment letter.

Visit homehealth4america.org for more information.