CMS Prior Authorization Could Gut the Home Health Benefit - 6/9/2016

For some reason the people who run the Center for Medicare and Medicaid Services (CMS) have decided to move forward with a Prior Authorization Demonstration for Home Health Agencies in five states.  Over 100 members of Congress have written letters to CMS in opposition of the Home Health Prior Authorization Demonstration.  But CMS “the all knowing all for the greater good of Medicare”  has decided to move forward anyway. 

The rule published on June 8, 2016 sets up a three-year Home Heath Prior Authorization Demonstration that impacts the state of Illinois beginning no earlier than August 1, 2016, Florida no earlier than October 1, 2016, Texas no earlier than December 1, 2016, and Michigan & Massachusetts no earlier than January 1, 2017.

Under this demonstration, a home health agency will be encouraged (Required To Get Paid) to submit the relevant MAC a request for pre-claim review, along with all relevant documentation to support Medicare coverage of the applicable home health level of service.  After receipt of all relevant documentation, the MAC will review the pre-claim request to determine whether the services level complies with applicable Medicare coverage and clinical documentation requirements.  The home health agency should submit the Request for Anticipated Payment (RAP) before submitting the pre-claim review request and begin provided the services while waiting for the decision from the MAC.

The MAC will communicate to the home health agency and beneficiary a decision provisionally approving (or Disapproving) payment after a submission of a request for pre-claim review.  For the initial submission of a pre-claim review request, the MAC will make all reasonable efforts to make a determination and issue a notice of a decision within 10 business days. (This is a 100% Medical Review for all home health claims in five states. How can we believe they can do this in 10 days?)  While you wait for approval you continue to provide services without knowing you will get the authorization.

After the first three months of the demonstration in a particular state, CMS will apply a payment reduction for claims that, after such prepayment review, are deemed payable, but did not first receive a pre-claim review decision.  As evidence of compliance, the home health agency must submit the pre-claim review number on the claim in order to avoid a 25 percent payment reduction.  The 25 percent payment reduction cannot be recouped or charged to the beneficiary and is not subject to appeal.

This must be stopped.  My recommendation is that you have all of your patients and employees call their members of Congress and Senators and tell them do not to let Medicare go the way of the VA.  I would contact every person in your local community, church members, family and friends and have them call their Congressman and tell them to “Stop the Home Health Prior Authorization Demonstration Program - Do Not Restrict My Medicare Home Health Benefits by Adding More Red Tape Like The VA”.

Temporary Link (Permanente Line Will Be Sent In Future Email)

https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-13755.pdf