Home Health Pre-Authorization Project

Feedback is Requested from Home Health Agencies

Pre-Authorization for Home Health Services? It’s a possibility! CMS recently proposed a new demonstration project for home health providers in Florida, Texas, Illinois, Michigan, and Massachusetts. The project is geared towards helping to assure that payments for home health services are appropriate before the claims are paid, which would then prevent fraud, waste, and abuse.

CMS would establish a prior authorization procedure similar to the Prior Authorization of Power Mobility Device (PMD) Demonstration. While the final version for home health could differ slightly than PMD if approved, this type of additional safeguard could cause considerable administrative burden and delay patient care. As an example, here are some of the process details for the PMD Demonstration project:

  • The prior authorization request would be submitted by the ordering physician/practitioner or supplier. This person is known as “the submitter.”
  • After receipt of all relevant documentation from the submitter, the Durable Medical Equipment Medicare Administrative Contractor would make every effort to review and communicate a decision within ten business days for initial submissions and 20 business days for re-submission on whether the PMD meets all Medicare coverage requirements. There would also be a mechanism in place to request an expedited 48 hour review, in emergency situations where a practitioner indicates clearly with supporting rationale, that the ten business day timeframe for a decision could jeopardize the beneficiary’s life or health.
  • CMS did not expect the program to create a significant delay in care or payment.

The Home Health Pre-Authorization would also follow and adopt prior authorization processes that exist in other health care programs such as TRICARE, certain state Medicaid programs, and in private insurance. The information required would be requested by Medicare contractors to determine proper payment or if there is a suspicion of fraud.

HEALTHCAREfirst is seeking input from home health providers not only in the states impacted, but in all states on how such a proposal would impact them and their patient care. Please submit feedback by responding to this blog.

The full proposal can be located here: https://www.gpo.gov/fdsys/pkg/FR-2016-02-05/html/2016-02277.htm

HEALTHCAREfirst will alert providers of any updates on this topic.

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  1. Kristin Finley - February 12, 2016

    Might as well do away with home health and send the patients back to the hospital and see what burden is placed on Medicare and HMOs. The administrative financial burden would be enormous for both CMS and providers. The amount of money spent on adding all the staff to do this, the back and forth wait time, delay in care and loss of continuity for recertification and rehabilitation progress would be enormous, i.e. 20 days to get authorization for recertification?? I thought the F2F was put in place to decrease this type of fraud. Do we even know the impact of the burden of implementing F2F vs. the success of decreasing fraud, or was this a type of punishment for all home health agencies because a few are dishonest. Or was the real reason for the F2F just be make it so close to impossible to comply, CMS is assured of their MACs to take back money and bankrupt home health agencies. I guess if there is only a few home agencies, they won’t have to pay for the service. This is insane.

    • Mary St. Pierre - February 23, 2016

      Numerous problems will result from imposing a prior authorization requirement on home health services. Following are a few of the reasons why, based on my experiences, that it should not be implemented. I know that there are many others. I hope that every home health agency will consider this proposal, identify additional negative effects such a proposal will have on the delivery of essential services in a timely manner, and inform CMS through the comment process.

      Talking Points Opposing Prior Authorization for Home Health1.

      1. Impediment to timely admission and prompt delivery of necessary care

      2. Negative impact on hospitalization/rehospitalization rates, emergency department visits and cost of care

      3. Fails to recognize the inherent difference between nonessential power mobility devices that have little negative impact on a person’s health and essential home health services (e.g. medication teaching and reconciliation, IV infusion, diabetic care and teaching, wound cared) which are often required within 24 hours (or less) and cannot be delayed

      4. Presents roadblocks to admission to home health within 24-48 hours as recommended by quality measures (NQF) and research findings (Naylor, Coleman, etc. ) and found to result in reduced re-hospitalization and ED rates

      5. Could lead to noncompliance with Home Health Conditions of Participation which require admission to HH within 48 hours of referral

      6. Fails to recognize the importance of regulatory requirement to carry out initial and comprehensive assessments in order to determine service needs.

      7. Is a duplication of existing requirements that safeguard against fraud and abuse: physician orders, certification

      8. Takes gatekeeper role of control and oversight of home health services out of the hands of the physician and puts it into the hands of MAC reviewers

      9. Fails to address that F2F encounters may take place after home health admission, within 30 days

      10. Increases the cost of care health care delivery (physicians , HHA, MAC reviewers time/cost)

      11. Creates a paperwork requirement that will have little or no impact on preventing fraud and abuse since evidence of medical necessity and delivery of skill

    • S Tatum - March 15, 2016

      Exactly! I agree 100%.

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