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
