The Centers for Medicare & Medicaid Services recently announced plans to suspend the application of a mandatory regulation on providers of skilled home health care, which was widely praised by leaders in the Medicare post-acute care sector for demonstrating an increased recognition of the human, clinical and fiscal value home health offers the Medicare program and the 3.5 million older Americans who annually depend on the home health benefit.
CMS had recently put forth a Pre-Claim Review Demonstration, which called for mandatory regulatory requirements imposed on America’s home health agencies in an attempt to reduce improper payments. While it is widely acknowledged that program integrity problems must be solved to reduce wasteful spending, there are varying perspectives on how — and if — overly burdensome Medicare rules produce positive results.
Under Pre-Claim Review, a third-party contractor must approve all home health claims before Medicare is authorized to make payment for the delivery of care services. The idea was to ensure American tax dollars were put to good use by making sure only patients who needed home health care services were getting them and to root out potential bad actors looking to commit fraud.
In theory, that sounds reasonable. Unfortunately, the results were less than optimal when applied across one state last year. Not only did the Pre-Claim Review fail to address fraud, it led to confusion and extra cost in home care and a slew of inappropriate care denials for elderly Americans due to varying and burdensome regulatory requirements on referring physicians and home health agencies.
Home health agencies reported numerous denials for necessary patient care and unmanageable administrative requirements, putting sick patients at risk and driving up costs for agencies already strapped thin. Reports of technical failures poured in from across the state. Routine services such as physical therapy and nursing care for knee replacement patients were denied simply because the Medicare contractor’s electronic submission system didn’t work properly. Worse yet, the demonstration put government squarely in between the doctor and the Medicare patient.
Fortunately, Health and Human Services Secretary Tom Price and CMS Administrator Seema Verma listened to program concerns raised by bipartisan lawmakers and home health leaders and announced plans to suspend the program. By suspending this troubled program, I hope the provider community can work collectively with the Administration and other stakeholders to develop targeted program integrity reforms that meet Medicare’s goals of cutting cuts and reducing fraud without putting patient interests in the crosshairs.
We are grateful that lawmakers in Congress — particularly Sens. Bill Nelson (D-Fla.) and Marco Rubio (R-Fla.) — spoke out strongly against the program, demonstrating unity across the aisle due to the potential negative impacts on American seniors and persons with disability.
The new administration has the authority to dramatically change the course of the flawed Pre-Claim Review Demonstration as well as other home health regulations that do nothing to improve care, but only pile on duplicative paperwork requirements. I urge them to look closely at what works and what doesn’t, and consider the bearing on home health delivery, cost and quality.
We look forward to working with CMS to expand and strengthen the role of home health in our nation’s healthcare delivery system, which includes developing targeted program integrity systems that are tested and effective. Home health leaders and government agree that we must create solutions that prevent the distribution of improper and fraudulent payments, but a Pre-Claim Review policy is not the right solution.
We thank Medicare and Congress for recognizing the value of skilled home health care in optimizing patient outcomes, reducing health care costs and improving the overall patient experience.
Keith Myers is the chairman of the Partnership for Quality Home Healthcare and CEO of LHC Group.
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