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.

February 9, 2016

Click Here to Leave a Comment Below