Home Health Care Group Sues CMS Over Pre-Claim Audit Pilot Program

Published December 28, 2016

A national home health care advocacy group has announced plans to sue the federal Centers for Medicare and Medicaid Services (CMS) over a pilot program requiring home care providers to pre-file reimbursement claims for auditing before submitting the claims for payment.

Implementation of CMS’ Pre-Claim Review Demonstration (PCRD) began on August 3, 2016, in Illinois, one of five states targeted by CMS for extraordinarily wasteful Medicare spending. CMS subsequently delayed the pilot’s implementation in Florida, Massachusetts, Michigan, and Texas, “based on early information from Illinois,” according to program update posted online by CMS on October 5, 2016.

The demonstration “is currently ravaging our Illinois members and threatening to do the same across the country,” states an October 25, 2016, press release by the National Association for Home Care and Hospice.

The pilot program requires home health care companies to obtain physician signatures on treatment plans, which are usually filled out by midlevel providers, early in the treatment process. Program opponents say the program burdens home health care agencies with accelerating a weeks-long signature procurement process in which physicians have no incentive to respond quickly, Home Health Care News reported in September 2016.

In 2015, 59 percent of Medicare home health care payments were deemed improper, CMS reported in June 2016. The more than $9 billion in improper payments exceeded the 2013 improper payment rate of 17.3 percent, or $3 billion, Modern Healthcare reports. Improper payments include fraudulent claims, funds directed to the wrong recipient, missing documentation of funds, insufficient funds, and improper use of funds by recipients.

Blunt Scalpel

Joshua Archambault, a senior fellow at the Foundation for Government Accountability and the Massachusetts-based Pioneer Institute, says the home health care industry is a known source of fraudulent Medicare claims.

“It is well-documented that the home health services arena is one of the hardest areas to monitor, as care is delivered in private and enrollees have little incentive or are often unaware of when bad-apple providers are committing waste and fraud using them, as the patient, to do so,” Archambault said.

Auditing providers’ claims before allowing them to apply for reimbursement slows down all providers to catch a few bad ones, Archambault said.

“Prior authorizations are one blunt method to try to get a handle on some of this abuse,” Archambault said. “It is a relatively common practice used by private insurers for certain high-cost services and procedures and is almost always controversial. Prior authorization will save money, but it will also delay care for many.”

Slightly delaying payment to providers could prove necessary to stop Medicare fraud before it happens, Archambault says.

“The performance metrics for Medicare are to pay as quickly as possible and ask questions later,” Archambault said. “If, instead, the payment was delayed slightly so credit-card-like fraud analysis could be run, many of these questionable claims would be denied before a check is even issued.”

Suggests Patient-Centered Reforms

Rewarding Medicare recipients for choosing trustworthy home health care providers would discourage fraud, Archambault says.

“One reform would be to grant enrollees more financial control over their coverage and care,” Archambault said. “They should be rewarded for using high-value providers, and the money should follow them. If abuse is taking place, they would see the impact on their health account and take actions to report it and stop it. Right now, most do not have that incentive.”

Requiring patients instead of CMS auditors to approve treatment plans is another way to reduce waste, Archambault said.

“[A] second [reform] would be to get approval from the patient of the care that is going to be delivered,” Archambault said. “If the answer is ‘no,’ then the home health provider should have to provide proof that services are still needed in order to deliver them.”

Ben Pyle ([email protected]) writes from Cedarville, Ohio.

Internet Info:

Luke Karnick, “DOJ Launches Task Forces to Stop Abuse of Elder Patients,” Health Care News, The Heartland Institute, May 11, 2016.

Dustin Siggins, “Medicaid Fraud Prevention Bill Receives Unanimous Support in U.S. House,” Health Care News, The Heartland Institute, August 14, 2016.

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