In April 2017, the Centers for Medicare and Medicaid Services (CMS) abandoned a multi-state Medicare Pre-Claim Review Demonstration Model that had so many flaws it never made it out of the initial implementation state, Illinois. The latest proposed model promises to improve on the past model and boasts of greater flexibility and choice for providers in demonstration states (Illinois, Ohio, North Carolina, Florida, and Texas). Instead of having to follow the strict pre-claim review procedures of the earlier model, or face a 25% payment reduction for home health services, providers will be able to choose from either 100% pre-claim review or 100% post-payment review, or face a 25% payment reduction. CMS states that these review processes will achieve the following:
- Help ensure that payments for home health services are appropriate;
- Further develop improved procedures for the identification, investigation, and prosecution of Medicare fraud occurring among home health agencies;
- Protect the trust fund; and
- Reduce appeals.
For over half a century, the public has believed that CMS (and its’ administrative predecessors) have strived for appropriate payments in the Medicare program. However, before purposeful progress can be achieved to address fraud in the Medicare program, CMS must first ensure that Medicare contractors know Medicare law. The Center for Medicare Advocacy recently participated as legal experts in reviewing an OIG audit performed by a Medicare contractor. The contractors’ medical reviewers misunderstanding of Medicare law was shocking. Even more stunning was the fabricated standards applied to deny legally-defensible cases. Equally disturbing is that these same contractors are charged with educating providers about Medicare coverage. The dissemination of misinformation by contractors is unconscionable and must be corrected. That is how the trust fund will be best protected, by ensuring beneficiaries are properly approved for legally covered services. Finally, the goal of reducing appeals will only be appropriate when inappropriate denials are reduced.
The Center for Medicare Advocacy has no information offering assurance that this proposed demonstration program will be an improvement over the earlier failed model. Adding the alternative option of 100% post-payment review does not address the concerns that brought down the 2016 model in Illinois – onerous, rigid requirements that had to be met in unreasonable sequential order, derailed as soon as a doctor could not be reached for signature or a file could not be uploaded to a Medicare contractor properly. Under the failed demonstration, access to home health services in Illinois was reduced for beneficiaries by a double-digit percentage. Was that fraud reduction or the result of unreasonable administrative barriers for providers, who were then unable to continue the fight to serve Medicare beneficiaries? And the Medicare beneficiaries who lose access in those battles are the most vulnerable patients, with long-term chronic conditions.
CMS’ announcement of the new “Review Choice” Demonstration mistakenly stated that they had “posted a 60-day Federal Register Notice to allow providers the opportunity to review and comment” on the revised demonstration. (Emphasis added). Certainly CMS meant to include beneficiaries and their advocates among those interested parties and members of the public who are legally entitled to comment and whose information CMS should consider when they review comments.
Public comments on the proposed action must be received by July 30, 2018. The Center for Medicare Advocacy will provide draft comments ahead of the due date for any organizations or individuals who wish to sign-on or use them to draft their own comments.
June 14, 2018, K. Holt
 With the option to expand to other states in the Palmetto/JM Jurisdiction.