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As discussed in our March 2, 2016 CMA Alert, the Centers for Medicare & Medicaid Services (CMS) published a notice in the Federal Register in February 2016 announcing its effort to seek approval from the Office of Management and Budget (OMB) to “collect information” pursuant to a demonstration project to identify, investigate and prosecute fraud among Medicare home health agencies by requiring prior authorization before processing claims for home health services in several states.

On April 5, 2016, the Center for Medicare Advocacy submitted comments to CMS, available here. Among the points made in opposition to this proposal, the Center noted that:

  • A blanket, state-wide prior authorization program applied to all home health services as outlined by the notice will lead to both unnecessary delays and denials of medically necessary care for Medicare beneficiaries who need home health services.  Such barriers will affect both those who need home health care on a short-term basis as well as those who have ongoing, chronic care needs.
  • In our experience, beneficiaries already face almost insurmountable odds when appealing claims denials. Instituting a prior authorization process as an additional barrier before the administrative appeals process can begin will make obtaining coverage even more difficult.
  • This proposal would also place tremendous additional pressure on the already over-burdened health care delivery system, creating more bottlenecks from providers’ offices to hospitals to skilled nursing facilities to homes, further slowing urgently needed care to beneficiaries, and allowing beneficiaries’ conditions to worsen in the process.
  • This proposal will not advance the stated cause to “assist in developing improved procedures for the identification, investigation, and prosecution of Medicare fraud occurring among HHAs providing services to Medicare beneficiaries.” The types of errors leading to improper payment identified by CMS are led by a 90% rate of “insufficient documentation errors” – not the type of fraud CMS seeks to combat.

In short, the Center stated that, if implemented, this demonstration would undoubtedly negatively impact access to necessary home health care for many Medicare beneficiaries. Requiring prior approval for every prospective home health recipient will effectively delay and deny home health coverage for countless Medicare beneficiaries, often when they are most medically vulnerable. The Center therefore urged CMS to withdraw its proposed prior authorization demonstration.

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