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Can we talk about fraud? It exists. It’s not good for Medicare. Efforts to eliminate its damage to the program are necessary.  But CMS’ war on fraud seems to be indiscriminate, full of tactical errors and collateral damage. Rather than carefully targeting the perpetrators of fraud, a wide net is cast, resulting in legitimate claims for necessary care sinking into a sea of denials.

The latest victims include an 87-year-old woman suffering from congestive heart failure, an individual in need of wound care and gait training to remain safely at home, and a person with multiple sclerosis requiring significant ongoing physical therapy. These are examples of denials made in the new Home Health Pre-Claim Review Demonstration Model (PCRD) launched last month in Illinois. While the Demonstration is still active in Illinois, further application in other states has been suspended as a result of myriad problems with legitimate claims.

The premise of pre-claim and prior-authorization reviews might seem to make sense – in theory, they require documentation for claim approval up-front instead of later in the process, after the delivery of care. In a perfect world, all the pieces that need to come together would be completed and submitted when a person seeks care. The physician or other provider would produce all the necessary documentation in the correct format, all the required evaluations and assessments would be flawlessly completed by skilled nurses and therapists, and the information would be submitted in the specific order required by the Medicare contractor. But, too often, pre-claim review and prior authorization just become excuses for pre- or prior- denial. When up to 80% of claims are denied because they have not achieved the prescribed perfection required, beneficiaries are denied access to necessary care and providers are reluctant to offer care in the future.

After correcting difficulties uploading documents and other technical glitches in the PCRD, two major problems continue to surface. The first problem is with the tightly dictated standardized formatting that the Medicare contractor requires in order to process pre-claim approvals. The second concerns issues with the face-to-face certification requirements.

The “User Guide & Checklists” for the “Home Health Pre-Claim Review eServices Submittal Request”, while intending to be comprehensive, creates an impractical bar for home health agencies. When one piece of data is not provided in a very specific format, and in the prescribed order, the entire claim is denied. The level of detail requires a clinically educated person to review every case to tease information out of every record to complete the required forms. Since there is no standardized practice by which providers (e.g. doctors/therapists/hospitals) write chart notes, narratives, and orders, this new system – that apparently assists review for the Medicare contractor – is a nightmare for the home health agencies. They are overwhelmed by the requirements, which serve no apparent substantive purpose, but which have quickly impacted access to care for beneficiaries.

Under the PCRD, all the required documentation from the providers (completed, signed and dated correctly) must be chased down up-front, rather than in a manner that allows time for the agencies to get the documentation from the doctors and other providers. Again, this creates obstacles to care for beneficiaries.

Successfully completing the face-to-face provider’s certification requirement is another great challenge in the PCRD, still further jeopardizing care access for beneficiaries. While requirements of this certification have been unclear since its implementation in 2011, the issues with face-to-face certifications became worse in 2015 (ironically, when the narrative requirement was dropped and the standards became more ambiguous). Pre-claim reviews are further highlighting the poorly designed, implemented, and inconsistently applied face-to-face requirements.

Additional documentation requests (ADRs) for the face-to-face certifications occurred about .5% of the time until the PCRD. Under PCRD, face-to-face certification scrutiny occurs 100% of the time – and now two doctors may be required to coordinate and to sign (if the patient is coming from a facility, the hospitalist and the primary care doctor). Guidance about how to complete face-to-face certifications have not allowed physicians, who are not compensated for the time necessary to complete these, to meet all the required, and often inconsistently interpreted, criteria. The legal definitions the reviewers are looking for are well outside the “wheelhouse” of doctors. Denials of face-to-face certifications are based on trivial and technical issues and miss the original intent of the requirement, which was to ensure a physician is aware of, and orders, the home health care. This causes understandable frustration for physicians, home health agencies, and beneficiaries.

Pre-claim reviews and prior-authorization may be intended as tactics in the battle against fraud, but in practice they are working to further interfere with legitimate claims for necessary care. They are eroding Medicare’s promise to provide necessary care for older people and people with disabilities, and harming the program’s integrity. There are other approaches to defeating Medicare fraud that CMS could adopt from other public concerns, such as “see something, say something,” neighborhood watches, or peer review. 


The PCRD is an inappropriate, over-inclusive counter to fraud. Medicare reports that 90% of potentially fraudulent activity in Medicare home health care is actually “insufficient documentation.”[1] However, insufficient documentation is not a valuable link to significant fraud. As a CMS official recently stated, major bad actors know very well how to provide documentation.

Medicare beneficiaries in real need of home health care are facing increasing access problems.  We urge CMS not to add to these barriers with technical claim requirements and inappropriate prior denials that encourage providers to stop offering care. The Pre-Claim Review Demonstration Model should be ended before it causes more harm to older people, people with disabilities, and their families.

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