Home Health Lashes Back Against Preauthorization Proposal

A recent proposal that would require home health agencies to receive prior authorization before caring for patients has been met with an onslaught of backlash by the industry. The period for home health agencies to submit comments on the preauthorization proposal from the Centers for Medicare & Medicaid Services (CMS) ended Tuesday with close to 250 comments from industry affiliates.

The comments were largely against the rule, which CMS has touted as a means to reduce fraudulent and abusive practices. The new model would require agencies to hold off care until they receive authorization, instead of verification after claims are made. Home health agencies maintain that the rule would slow down care to patients who need it and result in heavy administrative burdens on the industry and CMS.

The pilot proposal was quietly announced by CMS in the Federal Register in early February. In its current form, the proposed rule would pilot in Florida, Texas, Illinois, Michigan and Massachusetts.


A Sweeping Slowdown

The rule, if enacted, could require home health agencies to wait on authorization when home health patients require changes to their care plans. The result could potentially slow down care for patients in need and leave home health agencies at risk.

“It’s going to be harmful for a significant portion of patients that have issues that arise unexpectedly,” John Reisinger, a home health care consultant, CPA and principal of Innovative Financial Solutions, told Home Health Care News. “There are going to be situations that occur during the treatment in the home in which a change has to be made to the original plan of care. If that’s the case, we’re going to have to get that approved before providing other care. It’s absolutely ridiculous.”


Multiple industry groups, including the The American Hospital Association, commented on the proposal in the days before the open comment period ended. A common theme among the comments from groups: The sweeping regulation the proposal would enact across the five states named in the pilot is too broad to actually achieve its goals.

“We urge CMS to focus on interventions that target [home health] agencies with likely fraudulent practices, based on analysis of Medicare claims,” AHA Executive Vice President Tom Nickels wrote. “Such an approach would be more effective than using an across-the-border prior authorization, which would burden the entire home health field in these states, as well as already-overloaded Medicare contractors. CMS also must include comprehensive protections for beneficiaries who would likely be affected by this policy, such as provisions to ensure timely prior authorization coverage decisions and beneficiary appeals—details of which are absent form this proposal.”

As CMS continues to push for policies that ultimately aim at cracking down on Medicare fraudulent practices and reduce overall health care costs, some advocates for the industry say the policies are poorly directed against home health instead of other pain points along the care continuum.

“The referral source is supposed to be the front line in insuring that what is being done in home care is proper and necessary,” Reisinger said. “All CMS is doing is creating a duplicative step that costs the program money and delays care.”

Participating in Policy Making

With so much seemingly at stake for home health industry, the comment period offered an opportunity for agencies, employees and others within home health to voice their opinions about the proposal and inform CMS about the potential administrative burdens and patient care concerns.

Reisinger recently urged home health agencies to comment on the proposal in an effort to deter what could be a “detrimental” new rule for the industry. While roughly 250 comments flowed in on this proposal, Reisinger says higher participation rates could make a bigger impact in the rule-making process with CMS.

“The comments make a big difference,” Reisinger said. “We see changes to proposed rules based on comments that are submitted. Any participating party in home health can comment. …People complain about what CMS is doing, but they don’t take the time and the effort to comment. It’s one of the areas where this industry has always fallen woefully short.”

Some of the comments from the industry take issue with other requirements home health agencies currently have to follow, including giving care to a patient within 48 hours of a referral. Waiting for prior authorization could slow down this process overall, delaying care at the OASIS stage and adding administrative burdens for CMS and agencies alike.

“Going to a prior authorization process is going to cause a rewrite of the conditions of participation,” Reisinger said.

Following the closure of the comment period, CMS will review the submitted comments from members of the industry and likely release a finalized pilot. Reisinger hopes to see the rule scrapped entirely.

Written by Amy Baxter

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