Citing Patient Concerns, Durbin, Illinois Lawmakers Call For Delay Of Medicare Home Health Pilot Program
CHICAGO – U.S. Senator Dick Durbin (D-IL), along with the entire Illinois delegation, today called on the Centers for Medicare and Medicaid Services (CMS) to delay further implementation of the Pre-Claim Review Demonstration (PCRD) in Illinois, which has resulted in unintended consequences for patient access to care and provider capacity for Medicare home health services. Currently, between 60-80 percent of PCRD submissions in Illinois are being non-affirmed by the Medicare Administrative Contractor (MAC). This non-affirmation rate is leaving many patients without clarity on whether their medically necessary care will be covered. As a result of Illinois’ experience to date, CMS is delaying implementation of the pilot in Florida, Texas, Michigan, and Massachusetts.
“Seven weeks into the PCRD, the experience of this pilot in Illinois has resulted in severe burdens on patient access to care and provider capacity. We urge CMS to delay further implementation of the PCRD in Illinois, which CMS has already announced they will do for other states,” wrote Durbin in a letter to CMS Acting Administrator Andy Slavitt.
When CMS first proposed to impose the mandatory home health prior authorization demonstration, Senator Durbin, along with Senators Nelson (D-FL) and Stabenow (D-MI) wrote to CMS to outline concerns about the broad scope of the demonstration, its impact on beneficiary access to services, and the potential impact on Medicare costs due to delays in medically necessary services and readmissions. CMS took into consideration some of these concerns regarding prior authorization and amended the demonstration accordingly. However, Illinois’ experience under the PCRD has been alarmingly burdensome for home health providers, which is harming patient access to care.
Durbin shares CMS’ interest in identifying Medicare fraud and reducing improper payments and has expressed a strong desire to continue working with CMS to address Medicare home health fraud, which a recent Department of Health and Human Services Inspector General report found was prevalent in Illinois. However, Durbin remains concerned that implementing the PCRD as presently structured – and without sufficient education and training – could jeopardize the delivery of care to beneficiaries in need.
Full text of the letter is available below:
October 3, 2016
The Honorable Andy Slavitt
Acting Administrator
Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201
Dear Acting Administrator Slavitt:
We write to express concerns regarding the Centers for Medicare and Medicaid Services’ (CMS) Pre-Claim Review Demonstration (PCRD) that began implementation in Illinois on August 3, 2016. When CMS first proposed to impose the mandatory home health prior authorization demonstration, many of us wrote to your agency to outline concerns about the broad scope of the demonstration, its impact on beneficiary access to services, and the potential impact on Medicare costs due to delays in medically necessary services and readmissions. We appreciate that CMS took into consideration some of these concerns regarding prior authorization and amended the demonstration accordingly. However, seven weeks into the PCRD, the experience of this pilot in Illinois has resulted in severe burdens on patient access to care and provider capacity. We urge CMS to delay further implementation of the PCRD in Illinois, which CMS has already announced they will do for other states.
Under the PCRD, Illinois home health agencies have begun to submit documentation to the state Medicare Administrative Contractor (MAC) earlier in the process of providing patient care to verify that claims requirements are being met. The justification for imposing the mandatory PCRD in Illinois – along with Florida, Massachusetts, Michigan, and Texas – was due to concerns regarding unnecessary utilization and improper payments. We share CMS’ interest in identifying Medicare fraud and reducing improper payments, and look forward to continuing to work with your agency to address Medicare home health fraud. We are cognizant of the high rates of Medicare home health fraud that have been identified in Illinois, including in the recent Department of Health and Human Services Inspector General report, which uncovered numerous home health agencies and providers in Illinois whose Medicare claims were characteristic of fraud. However, we remain concerned that implementing the PCRD as presently structured, and without sufficient education and training, jeopardizes the delivery of care to needy beneficiaries.
Illinois’ experience under the PCRD has been alarmingly burdensome for home health providers, which is harming patient access to care. Presently, our understanding is that between 60-80 percent of PCRD submissions in Illinois are being non-affirmed by the MAC. This non-affirmation rate is unacceptable, as patients are left without clarity on whether their medically necessary care will be covered. On September 19, 2016, CMS announced that based on Illinois’ experience under the PCRD, CMS will postpone the expansion of the demonstration to other states. While we appreciate the recognition that the current PCRD experience is problematic, CMS must take immediate action to provide relief for Illinois.
In postponing the PCRD expansion to the other states, CMS stated that “additional education efforts will be helpful before expansion of the demonstration to other states.” In Illinois, too many of the non-affirmed claims are being transmitted with generalized responses or without any explanation or guidance from the MAC, which leaves patients and providers with uncertainty on how to rectify their case, and whether care should continue to be furnished if there is no guarantee of paid claims.
We urge CMS to immediately grant the state of Illinois the same PCRD delay that your agency has provided to Florida, Massachusetts, Michigan, and Texas, until education and guidance for home health providers, the state MAC, and patients are improved. If the lessons from Illinois prove that PCRD is not adequately developed for implementation in those states, then our constituents and provider organizations deserve the same consideration.
We appreciate your immediate attention to this matter. We look forward to working together on strengthening oversight and improving program integrity while maintaining quality care for seniors in the most cost-effective, medically appropriate settings. We urge you to consider the negative impact that the PCRD is having in Illinois, and take steps commensurate with those taken for other states to preserve patient access.
Sincerely,