Federal Lawmakers Seek Pre-Claim Data Before Speaking Up

In light of the decision by the Centers for Medicare & Medicaid Services (CMS) to delay the implementation of the Pre-Claim Review Demonstration in Florida, Texas, Massachusetts and Michigan, home health providers in Illinois say they are reeling as the program is still underway there. Agencies have spoken out about high denial rates on their claims submissions, inconsistency in the pre-claim process and significant administrative burdens in their attempts to comply with the regulations.

The desperation has left many wondering how lawmakers are responding to the situation. Home health agencies recently voiced their complaints over a lack of action from lawmakers representing Illinois in Washington, D.C.—especially in light of the fact that the two U.S. Senators from Florida, Ben Nelson (D) and Marco Rubio (R), sent a letter to CMS speaking out against pre-claim prior to the delay being granted.

“Since the decision by CMS to delay it for all other states but Illinois, there has been some response [from lawmakers] this week, but nothing coordinated yet in Illinois,” Micah Roderick, director of public policy at the Illinois Homecare & Hospice Council (IHHC), told Home Health Care News. “We are hoping and waiting at this point.”


The IHHC is working with other national industry groups, including the National Association for Home Care & Hospice (NAHC), to lobby for the pre-claim demonstration to be dismantled.

Work in Washington

As the stories continue to roll in about the unsuccessful implementation in Illinois, lawmakers in Washington may be waiting for new data to leverage in their efforts to fix the demonstration’s problems. While there has been no coordinated effort from Illinois lawmakers in Washington to halt pre-claim in Illinois yet, Sen. Dick Durbin (D-IL) spoke up about the issue before it was implemented, and is monitoring incoming data, his office told HHCN.


“Senator Durbin is aware of the issues around the implementation of the pre-claim review demonstration in Illinois and working toward a solution,” said a spokesperson from Durbin’s office. “Senator Durbin expressed his initial concerns in a letter to CMS this spring prior to the start of the demonstration, and CMS changed its original proposal in response to the issues we raised. We are currently collecting information and data regarding the impact of the demonstration on patients and providers, and have been, and will continue to be, in touch with CMS to ensure continued patient access to medically necessary, cost-effective services while maintaining program integrity.”

Both Senators Durbin and Mark Kirk (R-IL) signed a bipartisan letter to Andy Slavitt, acting administrator to CMS, in April over their concerns of the program.

“Sen. Kirk joined a bipartisan letter in April expressing concern over this demonstration,” a spokesperson told HHCN. “Based on CMS response and concerns over patient access to care, Kirk is asking CMS to scale back the demonstration. Efforts to improve Medicare program integrity are critical to the fiscal future of our country, but shouldn’t come at the expense of vulnerable seniors that need and prefer the comfort of their own homes.”

Rep. Tammy Duckworth (D-IL) has similarly stated she is concerned about the issue and is seeking more information and data on the problems agencies are facing in the Prairie State.

“Congresswoman Duckworth has and will continue to work with her colleagues to ensure that the nearly 200,000 Illinoisans who depend upon skilled home health services through Medicare can continue receiving the care they need and deserve,” Ben Garmisa, communications director for Duckworth, told HHCN. “The Congresswomen is concerned with reports that the pre-claim review demonstration could negatively impact care and put patients at risk, and she is seeking additional information regarding implementation problems. She will keep pushing to ensure CMS takes these concerns, which she shares with patients and providers alike, into account as it works to reduce fraud and waste.”

Both lawmakers underscored their continued work with CMS, though the situation remains dire for agencies stuck in the pre-claim process.

“It’s hard to find words right now,” Roderick said. “It’s just so bad. It’s puzzling why CMS is looking at their own data and not stopping [the program]. But we’re also waiting for that data.”

Pressing for Relief

Other industry groups are calling for a halt to the program in Illinois until CMS can figure out how to make it work. The Visiting Nurse Associations of America (VNAA), a national trade association that supports, promote and advocators for home health care, supported the decision to delay implementation elsewhere, but also called for suspension in Illinois and even spoke up for scrapping the program entirely.

“VNAA continues to believe that Pre-Claim Review for home health services is not the most effective approach for reducing Medicare fraud or abuse and should be discontinued,” Tracy Moorhead, CEO and president of VNAA, said in a statement.

For the time being, IHHC urges home health agencies to continue speaking up if they are having issues with the demonstration in Illinois.

“Our message is that we’ve got to keep it up,” Roderick said of the response from home health agencies in Illinois. “Providing data on how this is affecting the patients and providers themselves is what we really need in order to show Congress, who has really yet to act together, that this is a very serious situation here in Illinois.”

Written by Amy Baxter

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