Medicare Moratorium on New Providers Might Punish Innocent

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By James Swann

The expansion of an anti-fraud initiative that blocks new ambulance and home health providers from enrolling in Medicare in some states might harm legitimate providers that were trying to enroll.

Ambulance and home health providers told Bloomberg BNA they support the program’s goal of reducing Medicare overutilization, but they said last year’s state-wide moratorium expansions prevented otherwise innocent providers from enrolling in Medicare.

The Centers for Medicare & Medicaid Services expanded the temporary moratorium program from selected counties to some entire states in July 2016. The program is designed to stop new provider enrollment in sectors where the CMS has identified a high risk of fraud and abuse.

The expansion affects all newly enrolling nonemergency ambulance providers in New Jersey, Pennsylvania, and Texas, and all newly enrolling home health agencies in Florida, Illinois, Michigan, and Texas.

Previously, moratoriums were in effect in certain counties surrounding large metropolitan areas in those states.

The American Ambulance Association supported the initial, more limited moratoriums, but recognizes the burdens the expansions may pose on providers, Brian Werfel, a Medicare consultant with the AAA, told Bloomberg BNA.

Expanding the scope of the moratoriums from county to state level swept up many providers that were in the midst of enrolling in Medicare, Werfel said. The enrollment process can take up to five months, so providers that wanted to enroll near the original targeted areas were suddenly blocked from enrolling, he said.

CMS May Grant Waivers

The CMS can allow some providers to enroll through the use of waivers and should “liberally” use them, Werfel said. The waivers are doled out on a case-by-case basis and intended to help individual ambulance and home health providers enroll in Medicare in moratorium states, but Werfel said they haven’t been working as well as they should.

The regulation that governs the moratorium program makes clear that it applies to both new enrollment applications and enrollment applications that were pending when the moratorium went into effect, Werfel said.

“What you need to understand is that the enrollment process can take three to six months, depending on how quickly CMS completes its required site visit,” Werfel said.

For example, the ambulance provider moratorium expansions for the entire states of Texas, Pennsylvania, and New Jersey went into effect July 29, 2016.

Any provider that applied for enrollment in May, June or July 2016 did so without any notice that the moratorium would impact them, Werfel said.

A solution to the problem would be to impose the moratorium on newly submitted enrollment applications and grandfather in all pending applications, Werfel said.

The Affordable Care Act gave CMS the authority to impose temporary moratoriums on providers enrolling in Medicare, Medicaid, or the Children’s Health Insurance Program if there was a significant risk of fraud and abuse.

The initial moratoriums were imposed in July 2013 and covered enrollment in several counties in Florida, Illinois, and Texas.

They were expanded to counties in Michigan, Pennsylvania, and New Jersey in January 2014, and Medicare made the enrollment bans statewide in all six states in July 2016.

A temporary moratorium lasts for six months, but CMS can renew it for a six-month period an indefinite number of times.

State Expansions

The expansion was largely designed to close up some loopholes in the earlier targeted moratoriums, and there has been no evidence it has reduced access to care, William Dombi, vice president for law at the National Association for Home Care & Hospice, told Bloomberg BNA.

The CMS expanded the temporary moratorium to states because the agency felt fraudulent companies were locating in nonmoratorium areas and serving patients in moratorium locations, Dombi said.

However, Dombi said, the expansion blocked companies that had been deep in the Medicare enrollment process from becoming fully certified.

Dombi said he’d heard some indications that the moratoriums have increased the market value of existing home health agencies, as they aren’t facing any competition from new providers.

Dombi is a Bloomberg BNA advisory board member.

Prior Authorization

Medicare overutilization was the driving force behind the creation of the moratorium, but a better solution to the problem might be prior authorization programs, AAA’s Werfel said.

Prior authorization programs require that providers contact the CMS and get coverage approval before offering any services.

Werfel said a demonstration prior authorization program for home health services has reduced Medicare usage. If it can become a full-time program, it could eliminate the need for the moratoriums, Werfel said.

The pre-claims review demonstration program for home health began in August 2016 in Illinois, and has since expanded to Florida, Texas, Michigan, and Massachusetts.

The demonstration program has faced significant pushback from Congress and the home health industry. A bipartisan group of 27 Florida lawmakers sent a letter to HHS Secretary Tom Price in late February arguing that the program would unduly burden home health providers and potentially harm patient access to care.

The NAHC’s Dombi has also urged the HHS to drop the demonstration program. Home health agencies in Illinois have reported up to a two-month backlog in paperwork under the demonstration program, he said.

A separate prior authorization program for nonemergency ambulance services began in December 2014 in South Carolina, New Jersey, and Pennsylvania and expanded to Delaware, the District of Columbia, Maryland, North Carolina, Virginia, and West Virginia in January 2016.

Scaling Back

The temporary moratorium has become a given for most home care providers practicing in Florida for several years, but the new leadership at the CMS might be willing to scale back the program to individual counties, Bobby Lolley, executive director of the Home Care Association of Florida, told Bloomberg BNA.

Most existing providers don’t believe it has limited their ability to grow and expand, Lolley said, but he knows of about a dozen HHAs that were on the cusp of enrollment when the moratorium was expanded and had spent a lot of money in preparation, only to be blocked from the Medicare program.

Lolley said he believed if the right group made a push to scale back the moratorium and target it better, Congress would listen. A seniors group, for example, could make the argument that the moratorium has stifled competition and that more HHAs are needed.

The baby boomer population in Florida is huge and could certainly use more home health agencies, particularly in the panhandle and in Jacksonville, Lolley said.

To contact the reporter on this story: James Swann in Washington at jswann1@bna.com

To contact the editor responsible for this story: Brian Broderick at bbroderick@bna.com

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