CMS Launches Home Health Prior Authorization Requirement

Despite pushback from the home health industry and lawmakers, the Centers for Medicare & Medicaid Services (CMS) announced Wednesday it intends to move forward with a preauthorization requirement.

CMS’ plans for prior authorization, now dubbed the Pre-Claim Review Demonstration for Home Health Services, will roll out in five states as announced in February. The proposal aims to crack down on Medicare Fraud and abuse.

The demonstration will be rolled out in Illinois after Aug. 1; Florida after Oct. 1; Texas after Dec. 1; Michigan after Jan.1; and Massachusetts after Jan. 1.


Under the program, home health agencies in select states will be required to perform prior authorization before processing claims for services. The procedure would be similar to the Prior Authorization of Power Mobility Device (PMD) Demonstration, which CMS implemented in 2012 and requires prior authorization for scooters and power wheelchairs within seven states with high population of fraud- and error-prone providers.

“The main change under this demonstration is that HHAs will submit the supporting documentation while beneficiaries are receiving care,” according to a news release from CMS. “This earlier submission of documentation will undergo the new ‘pre-claim review.’”

The demonstration comes because of a 59% improper payment rate among home health claims in 2015, CMS stated.


CMS’ proposal has garnered criticism from the industry, and even those receiving home health services.

“When provided information on prior authorization for home healthcare services, senior voters have warranted concerns about how a demonstration might affect their access to needed skilled care in the home following an inpatient stay,” Keith Myers, Chairman of the Partnership for Quality Home Healthcare, said in a statement.

View a copy of the rule here.

Written by Kourtney Liepelt

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