Lawmakers Urge Medicare to Drop Home-Health Pre-Claims Review Plan

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By James Swann

Medicare should drop an upcoming program in Florida to review home-health claims prior to service, a bipartisan group of lawmakers says, arguing the program would unduly burden home-health providers.

In a Feb. 27 letter to HHS Secretary Tom Price, which was signed by 27 of the Florida delegation’s 29 members, the lawmakers said the demonstration program could lead to steep implementation costs for smaller providers as well as impede patient access to services.

The letter may find a sympathetic ear in Price, who was the original sponsor of legislation to suspend pre-claim review and require a study of its impact, William Dombi, vice president for law at the National Association for Home Care and Hospice in Washington, told Bloomberg BNA.

“The Florida delegation letter should encourage HHS Secretary Price to prioritize this issue and take the action suggested in the letter quickly,” Dombi said.

The letter to Price follows a September 2016 letter from Sens. Marco Rubio (R-Fla.) and Bill Nelson (D-Fla.) to Andy Slavitt, former acting administrator of the Centers for Medicare & Medicaid Services, that asked for a delay in the expansion of the program.

The Centers for Medicare & Medicaid Services’ pre-claims review demonstration is scheduled to begin in Florida April 1. It’s underway in Illinois and will eventually reach Texas, Massachusetts and Michigan. The three-year program requires providers to submit a request for provisional approval of coverage before a final claim is sent in for payment.

Pressure on CMS

A bipartisan letter is likely to increase the pressure on the CMS to drop or further delay the program, Gejaa Gobena, a health-care attorney with Hogan Lovells in Washington and a former Department of Justice prosecutor, told Bloomberg BNA.

Gobena said the pre-claim review program’s expansion has already been delayed once, and Price did introduce legislation to pause the program’s implementation.

The program was supposed to debut in Illinois, Florida and Texas in 2016, followed by Michigan and Massachusetts in 2017. However, it has been delayed everywhere but Illinois.

Gobena said the program is designed to reduce home-health fraud in states that have historically seen high levels of fraud. However, he said it shouldn’t be focused on all home-health providers, because home-health fraud in the five states are committed by a minority of providers.

Alternative program integrity measures could be more effective in deterring home-health fraud, Gobena said.

“Doing more on the front end to screen out potential bad actors opening up home-health agencies and targeted data analytics to identify potential bad actors is probably more efficient than subjecting all home-health agencies in a state to additional bureaucratic processes,” Gobena said.

Home-health agencies have to carry significant costs during a treatment episode, including paying the nurses or therapists providing the treatment, and a pre-claim review could place unnecessary costs and reimbursement pressures on home-health agencies that haven’t done anything wrong, Gobena said.

Issues in Illinois

While the Florida demonstration hasn’t begun, several flaws have already been uncovered in the ongoing program in Illinois, Dombi said.

For example, Dombi said, pre-claim review represents an increase in the workload for home-health providers, requiring them to reassign staff to paperwork duty. In Illinois, home-health agencies have reported as much as a two-month backlog in paperwork after just seven months under the demonstration, Dombi said.

The Illinois demonstration has only pointed out paperwork deficiencies in Medicare home-health claims. “Alternative, more efficient correctives should be employed in Illinois and nationally rather than continuing the pre-claim review project,” Dombi said.

Colin Roskey, executive director of the Partnership for Quality Home Healthcare in Washington and an attorney with Alston & Bird, said the Illinois program has been problematic for both providers and seniors.

Both administrative and cost burdens have increased, diverting resources from skilled clinical and advanced-care coordination services, Roskey said.

“The main problem with the PCRD [pre-claims review demonstration] is that it’s not targeted,” Roskey said, noting it applies to 100 percent of claims by 100 percent of providers in the state.

The Illinois program also hasn’t uncovered any evidence of fraud, Roskey said.

Roskey said the Partnership would continue to work with the CMS to develop less bureaucratic and more targeted measures to ensure claims accuracy, and said the group opposed the expansion of the program.

To contact the reporter on this story: James Swann in Washington at

To contact the editor responsible for this story: Kendra Casey Plank at

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The lawmakers' letter is at

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