Medicare Grounds Project Aimed at Combating Home Health Fraud

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By Mike Stankiewicz

The Medicare agency has grounded a controversial pre-claim review pilot in Illinois and delayed the pilot’s expansion in Florida, yet another health-care delay under the Trump administration.

The demonstration project was put on hold for at least 30 days in Illinois, beginning April 1, and did not expand to Florida as scheduled on April 1, after a decision released by the Centers for Medicare & Medicaid Services March 31. The delay follows a backlash against the demos from both lawmakers and the home health community.

Pre-claim review is a process in which a request for provisional affirmation of coverage is submitted for review before a final claim is submitted for payment, with the purpose of cracking down on fraud in home health agencies. It is different from prior authorization, in which a request must be submitted prior to the beginning of services. The pre-claim review occurs after services start but prior to the final claim being submitted.

In a Feb. 27 letter to Health and Human Services Secretary Tom Price signed by 27 of the Florida delegation’s 29 members, lawmakers said the program could lead to steep implementation costs for smaller providers as well as impede patient access to services. Sens. Marco Rubio (R-Fla.) and Bill Nelson (D-Fla.) also sent a letter in September 2016 to Andy Slavitt, then acting administrator of the CMS, that asked for a delay in the program’s expansion.

Colin Roskey, executive director of the Partnership for Quality Home Healthcare, told Bloomberg BNA in early March that the Illinois demo had been problematic for both providers and beneficiaries and that administrative and cost burdens have increased, diverting resources from skilled clinical and advanced-care coordination services. The Illinois demo also has not turned up any evidence of fraud, Roskey said.

The Partnership for Quality Home Healthcare is a coalition of home health providers.

Positive Response From Industry

Industry response to the CMS’s delay has been positive.

“We are pleased that CMS Administrator Seema Verma has chosen to suspend the program while improvements are made, which we believe will protect patient care,” Benjamin A. Breier, president and CEO of Kindred Healthcare in Louisville, Ky., said in an April 3 statement.

“Kindred fully supports appropriate program integrity efforts that address fraud and improper payments while preserving patient access and high-quality outcomes,” Breier said. “We are committed to working with CMS and Congressional leaders to develop an initiative that effectively targets improper payments without impeding patient access. As healthcare providers, we believe that we share in the responsibility to combat Medicare fraud and protect taxpayer funds.”

“We are incredibly pleased CMS listened to the concerns expressed by bipartisan lawmakers and home health stakeholders, and suspended the application of the demonstration,” Keith Myers, chairman of the Partnership for Quality Home Healthcare, said in a March 31 statement.

“While the Partnership fully supports CMS’ intent to reduce waste, fraud and abuse within the Medicare home health benefit, the pre-claim review demonstration is not the right approach and we are grateful CMS has chosen to suspend the program while improvements are made, which we believe will be beneficial to providers, physicians and patients alike,” Myers said.

The CMS said it would provide an update to providers via its website at least 30 days in advance of further developments related to the demos.

Representatives from the CMS press office didn’t respond to Bloomberg BNA’s request for additional comments on why the demos were halted, but did release a statement saying, “CMS is considering a number of structural improvements in response to feedback received on the demonstration to date.”

Continued Health-Care Delays

The pre-claim demo’s delay is only one of several Obama-era health-care regulations recently delayed by the Trump administration.

Other recent delays include the release of drug ceiling prices and penalties in the 340B drug pricing program, changes in Medicare’s conditions of participation and Medicare rules on bundled payments for cardiac care and joint replacements.

Some health-care stakeholders argue that more delays and regulation rollback are likely under the Trump administration.

“We are dealing with an administration that is anti-regulation,” Larry Goldberg, a health-care consultant in Oakton, Va., and a Bloomberg BNA advisory board member, told Bloomberg BNA April 4. “We are seeing delay after delay and we have to question whether this would be to review rules or is it because these were Obama regulations.”

“Some of these delays are going to turn into regulation rollbacks,” Ankur J. Goel, a health-care attorney with McDermott, Will & Emery LLP in Washington, told Bloomberg BNA April 4. “We have a new administration with an anti-regulatory approach.”

“All of this could be a new administration getting trying to get itself together and delay some regulations until they review it more,” Stephanie Zaremba, head of government affairs at Athenahealth in Watertown, Mass., told Bloomberg BNA April 4. “It’s always hard to gauge where an administration is going as far as regulations, so we’re just going to have to wait and see.”

To contact the reporter on this story: Mike Stankiewicz in Washington at

To contact the editor responsible for this story: Brian Broderick at

For More Information

The CMS release is at

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