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Medicare Rights Asks CMS to Withdraw Proposal to Require Prior Authorization for Home Health Care

This week, Medicare Rights submitted comments requesting that the Centers for Medicare & Medicaid Services (CMS) withdraw a proposal to explore requiring prior authorization for home health care services. These services include home-based skilled nursing and therapy care for people with Medicare who are homebound, meaning they are unable to leave their home without difficulty.

CMS cites reports of improper payments for home health care and the possibility of fraud as reasons for proposing a demonstration to require the use of prior authorization in select states. Under the proposal, certified Medicare home health agencies would be have to submit the currently required documentation prior to delivering services instead of with their submitted claims. Medicare Rights supports prior authorization demonstrations—for expensive power wheelchairs—for example; however in those situations, beneficiaries and suppliers can benefit from advance knowledge of Medicare coverage.

In the case of home health care, however, we are concerned that a prior authorization requirement may lead to unnecessary delays in accessing needed services. CMS states that the purpose of this proposal is to “assist in developing improved procedures for the identification, investigation, and prosecution of Medicare fraud occurring among HHAs [Home Health Agencies] providing services to Medicare beneficiaries.” Yet, we do not believe the proposed prior authorization demonstration will ultimately advance this cause.

CMS indicates that 90 percent of improper payments for home health care were the result of insufficient documentation. Yet, some insufficient documentation is caused by mistakes in the process of documenting need. For example, a doctor may leave off a date or a therapist may not complete a field. These are clerical errors—not fraud.

CMS estimates a cost to providers of over $25 million and a cost to CMS of $223 million to carry out the proposed demonstration. These costs are not insignificant. We do not believe these costs are warranted, given our overarching concerns with the proposed demonstration.

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