Legislation Introduced to Congress Would Delay Pre-Claim Review for One Year
September 28, 2016 03:55 PM
A bill introduced on September 28 by Reps. Tom Price (R-GA-6) and James McGovern (D-MA-2) would impose a one year moratorium on the Pre-Claim Review Demonstration (PCR) and requires the Center for Medicare and Medicaid Services (CMS) to report to Congress on the impact of the project on patients, home health agencies, physicians, and Medicare spending.
PCR began in Illinois on August 3, 2016 and almost immediately created chaos in the state’s home health agencies (HHA) and their patients. Problems included a 60-80 percent non-affirmed rate, burdensome and time-consuming paperwork, an inefficient electronic system that cannot process the documentation, physician unfamiliarity with what is needed for PCR due to poor education from CMS and their contractor, and considerable cash flow problems at agencies. At least one Illinois HHA has closed due to PCR. This led to HHAs withholding the start of care to patients until a favorable decision is received, resulting in longer hospital stays.
As Rep. Price wrote in a “Dear Colleague” letter to his fellow members of Congress, PCR “is creating barriers to care and forcing providers to incur significant unnecessary burdens to support an overly broad, untargeted, and ineffective demonstration.”
The CMS scheduled PCR to spread to Florida and Texas later this year, with Michigan and Massachusetts following no earlier than the start of 2017. However, earlier this month CMS announced a delay in the spread of PCR, due to pressure from NAHC and the weight of evidence from the Illinois experiment.
The Pre-Claim Undermines Seniors’ Health (PUSH) Actis co-sponsored by Rep. Kenny Marchant (R-TX-24) and Rep. Mac Thornberry (R-TX-13).
NAHC advocates have spent many hours working with lawmakers and their offices in recent months to alter or end pre-claim review and this bill is only the latest evidence of that hard work. Due in part to NAHC’s efforts, 116 bipartisan members of Congress signed a May 25, 2016 letter to CMS calling for the withdrawal of the original prior-authorization proposal. In addition, Rep. Tom Price (R-GA), whom NAHC has worked closely with on this issue, asked at a September 7 House Ways and Means subcommittee hearing on Medicare if the country would be “aided by a delay in this demonstration so CMS can get their act together?” NAHC also worked with Senators Bill Nelson (D-FL) and Marco Rubio (R-FL) to send a letter to CMS requesting the PCR demonstration not expand beyond Illinois.
In addition, NAHC staffers accompanied Sheila Guither, Sarah Ratcliffe and Micah Roderick – president, executive director and director of public affairs, respectively, for the Illinois HomeCare and Hospice Council on a series of visits to lawmakers on Capitol Hill to build support for opposition to PCR. They met with members of Congress from the Illinois delegation, including Mike Quigley (D-5), Peter Roskam (R-6), Tammy Duckworth (D-8), Jan Schakowsky (D-9), Bob Dold (R-10), Randy Hultgren (R-14), Adam Kinzinger (R-16), Cheri Bustos (D-17), Darin LaHood (R-18), and Senator Mark Kirk (R). NAHC staffers have also met with and contacted numerous other offices.
NAHC and its members are determined to find a superior alternative to PCR. It is possible to root out the fraud we all deplore without punishing patients and home health agencies. The Office of Inspector General (OIG) has identified characteristics commonly found in fraud cases, so CMS should concentrate its resources on pursuing those outliers, instead of punishing hard-working and law-abiding home health agencies and their patients. NAHC will continue to insist the PCR Demonstration in Illinois be brought to an end and that its harm not be spread to other states.
The National Association for Home Care & Hospice (NAHC) is asking everyone to contact their members of Congress and urge them to stand with the 3.5 million Americans who depend on home health services AND support the Pre-Claim Undermines Seniors’ Health (PUSH) Act.
NAHC is committed to staying on this issue and will continue to make the common-sense case against pre-claim review to Congress and the CMS.