Senators Join Call to Stop Medicare Prior Authorization Proposal
April 21, 2016 09:43 AM
A bipartisan coalition of Senators in states affected by the recent Medicare proposal to institute a home health prior authorization demonstration project have called on the Centers for Medicare and Medicaid Services (CMS) “to consider the impact that this demonstration could have on patient care and outcomes.” Senators Bill Nelson (D.-FL), Marco Rubio (R. -FL), Debbie Stabenow (D.-MI), Gary Peters (D. -MI), Richard Durbin (D-. IL) and Mark Kirk (R.- IL) wrote to Andy Slavitt, Acting Administrator of CMS, on April 18, expressing concerns with the CMS proposal.
“We commend CMS for its desire to strengthen the integrity of the Medicare program, but have heard from stakeholders who believe that the demonstration’s sweeping approach fails to adequately target bad actors and may restrict beneficiary access to timely services,” the letter stated . The letter further states that “imposing prior authorization for home health services would only increase the time seniors and other Medicare beneficiaries would have to wait to receive the care they need.”
Calling home health care a “critical service for seniors and people with disabilities that helps them stay in their home and communities for longer,” the Senators raise concerns about delayed care, extended hospitalizations, higher costs, and barriers to patient preference for home-based care.
On February 5, 2016, CMS released a proposal to institute a prior authorization system in five states: Florida, Michigan, Illinois, Texas, and Massachusetts. Under that proposal, nearly 1 millions claims annually would be subject to prior authorization reviews. If a home health agency does not get prior authorization, any later claim would be subject a 25% payment rate penalty. CMS alleges that the evidence of fraud in the targeted states justifies the project.
NAHC submitted formal comments on the proposal calling it unnecessary, overly broad in its application, ineffective in addressing the limited fraud that has been identified, and likely to erect harmful barriers to care of patients while increasing Medicare costs. Working with the state home associations in the affected states and other home care advocates, NAHC has initiated a campaign to gain allies in Congress and the beneficiary community. A comparable House letter is in development. In addition, numerous beneficiary advocacy groups have called on CMS to withdraw its proposal.
There is no public timetable for the CMS proposal. To date, all information regarding it comes from an obscure Paperwork Reduction Act notice in the Federal Register. NAHC also gained insights through a meeting with officials in the CMS Program Integrity division. Since that meeting, CMS officials have qualified their intentions, indicating doubts about the legal authority for the proposal and the process that CMS will use if it moves forward with it. However, CMS has not withdrawn the proposal to date.
The Senate letter is here.