Atrius Health Comments on Medicare’s Prior Authorization Demonstration for Home Health

The Centers for Medicare and Medicaid Services (CMS) recently proposed a demonstration pilot program targeted at reducing fraud and abusive practices occurring among home health agencies providing services to Medicare beneficiaries. This proposed rule would require five states, including Massachusetts, to obtain prior authorization for home health services.

If implemented, the prior authorization demonstration project would impact VNA Care Network, the largest non-profit home health provider in the state. VNA Care Network serves approximately 40,000 patients throughout eastern and central Massachusetts and provides about 500,000 certified home health service visits annually.

Our patients and their families rely heavily on the skilled services that VNA Care Network’s caregivers provide in order for them to stay at home. Atrius Health firmly believes that the value of care provided by VNA Care Network is not fully realized. They bring true value to both patients and the healthcare system by providing a cost-effective way to avoid hospitalizations and re-hospitalizations.

While we recognize and appreciate the important role that CMS plays in addressing fraud, waste and abuse in the healthcare system, the proposed pilots under consideration are a blunt instrument that has the real potential to cripple agencies with additional administrative requirements.

Home Health Agencies (HHAs) have already faced added administrative costs due to recent regulatory requirements imposed by CMS. These requirements have had a dramatic and profound impact on staff recruitment and retention in a competitive healthcare market. We question whether either of these proposals will provide an effective way to ferret out fraud by identifying those who have nothing more than financial motivation, or if they will simply burden those HHAs who are the “good actors”.

Over the past several years, home health agencies have been faced with an increasing regulatory burden that is deeply troubling to Atrius Health and the home health industry as a whole. Reimbursements have remained flat, or have decreased, despite increases in other fixed costs such as healthcare and salaries.

CMS has already instituted a number of accountability measures targeted at the home care industry, including but not limited to the following: Face to Face requirements, episodic payments, value-based purchasing, mandatory performance reporting and OASIS auditing.

While the proposed pilot states that the proposal under consideration falls under the “Paperwork Reduction Act of 1995”, we can hardly envision how this proposal will result in a reduction of paperwork for either agencies or the federal government for the following reasons:

• Potential delays in caring for patients – We believe that a prior authorization requirement (on top of the many requirements HHAs already encounter), could hinder the ability for HHAs to provide care to patients in need due to delays in processing paperwork.  In addition, we believe the proposed prior authorization requirements could directly and adversely impact HHAs ability to comply with Medicare’s Home Health Conditions of Participations (COPs) that require initiation as ordered by the physician or within 48 hours (whichever comes first).

• Potential increases in healthcare costs – Implementation of a prior authorization requirement could mean patients get discharged to their home without the supports and services they need, thus increasing the potential of unnecessary and costly re-hospitalizations.

• Increased burdens for physicians and HHAs – Physicians who order home health services and the receiving HHAs are currently required to provide significant documentation of the need for home health services, particularly the Medicare Face-to-Face Encounter requirement.  This proposal adds an increased paperwork burden on both physician and home health agencies while adding little additional value. Additional requirements with no clear value will add yet another layer of administrative burden that will be unsustainable for agencies.

• Additional costs to CMS – It should not be overlooked that any prior authorization program would also result in increased costs to CMS.  In order to prevent the interruption of patient care, CMS would have to devote significant resources to manage a prior authorization program at a time when major issues with responsiveness and payment lag times already exist.  CMS would have to create an entirely new process for beneficiary appeals, and more specifically, a process to expedite reviews and appeals when a denial of prior authorization would result in delayed discharge (thus potentially increasing healthcare costs).

For these reasons we strongly urge CMS to immediately withdraw this proposal and work with the HHAs and industry leaders to develop meaningful and impactful ways to target fraud and abuse without additional requirements that have questionable merit.  We believe there are more effective program integrity approaches that won’t penalize the vast majority of home health providers that simply want to provide cost-effective and high-quality care for their patients.