Medicare proposal puts patients and access to care at risk!

Here is the link to the website where the listeners can log on and find out who their congressmen are.  Our hope is that they call the legislators and let them know their feelings about this roadblock to their healthcare.  Our voice is stronger when we reach out, especially to those who are directly affected by these kind of demonstrations.  Here is the site:


CMS-10406 Medicare Probable Fraud Measurement Pilot; CMS-10599 Medicare Prior Authorization of Home Health Services Demonstration

Comments submitted by Molly Tomlin, Director of Clinical Practice and Regulatory Affairs

Texas Association for Home Care and Hospice

April 1, 2016

Thank you for the opportunity to submit comments on a proposed “pilot project” to require prior authorization (PA) for Medicare home health services in five states, including Texas. The proposal as described would implement a demonstration project to develop and test a Medicare prior authorization process for identifying and preventing fraud before home health claims could be submitted and processed.

 TAHC&H is firmly opposed to the home health prior authorization demonstration. While the industry recognizes the need for intelligent policies to combat fraud, waste and abuse – we are against policies that simply do not work and harm patients.

We oppose this proposal because:

 The proposal puts patients and access to care at risk.


  • If home health providers have to wait for approval before they see a patient, many vulnerable seniors will see significant delays in getting the care they need, thus negatively affecting patient outcomes.
  • The approach will present obstacles to reducing hospital readmissions and other innovative payment models Congress is advancing thus increasing cost to Medicare rather than decreasing costs.
  • CMS, rather than doctors, will decide what kind of care a patient should have access to. Unfortunately this is a preemptive utilization control measure rather than an outcomes-focused   quality initiative. 
  • The policy does not target agencies suspected of fraud. It instead implements an across-the-board, sweeping approach forcing every single agency to get prior-authorization before treating a patient.
  • CMS already has the resources in place to target suspected fraudulent agencies. They already know what the problems are and where they exist so why add more burdensome regulations on everyone? This is using an axe instead of a scalpel – not surgical or specific.
  • Our state and federal antifraud enforcement efforts are already well targeted and producing results, such as the H.E.A.T. task force is already designated to prevent fraud in major cities.
  • We believe that CMS has no legal authority to impose prior authorization on Medicare covered services. Congressional authorization has been limited to prior authorization of durable medical equipment and did not extend to home healthcare or any other medical service.
  • The proposed demonstration does not address risk areas for fraud in home health.   Rather, it adds significant administrative burden on both physicians and home health agencies by implementing a duplicative process since CMS already reviews payments and conducts audits both mid-episode, as well as retrospectively.
  • An across-the-board prior authorization program is a redundant procedural step that will raise administrative costs with little or no return. It is not manageable or realistic.
  • Providers already submit information to CMS on the proposed scope and duration of care. CMS can already recoup monies for unsubstantiated care.
  • Taxpayer dollars will not be used efficiently or effectively, as this is an unnecessary measure requiring substantial new resources on the part of CMS to prior-review over 900,000 claims each year.
  • In order to not interrupt patient care, CMS will have to sink major resources into pre-authorization procedures. This will be a massive administrative undertaking. There are already major issues with responsiveness and payment lag times on their end.
  • This is another burdensome government regulation placed on small business owners who are providing health care to our most vulnerable population.


  • Home health providers are already facing an unprecedented amount of government regulations and mandates in a time when federal decision-makers should be promoting cost-effective care for the rising senior population.
  • Perhaps there could be better tools to address home health risk areas, such as focusing on agencies that had Condition Level deficiencies or repeated deficiencies of the same nature.
  •  In order to get PA, an RN or PT has to visit the patient to assess their needs and report back.


  • A PA necessitates a visit to the patient for an initial assessment.
  • What if the agencies don’t receive a PA, even though the physician with all of his/her medical background says the patient needs home health? Now the agency must pay the nurse and has no way to bill the claim unless they are willing to take the 25% reduction in payment because they did not get the PA, as detailed in the CMS supporting statement.


Thank you for the opportunity to provide our comments on this Prior Authorization Proposal from CMS. However, The Texas Association for Homecare and Hospice takes a firm stand in opposing this proposal.



Molly Tomlin, RN, CLNC Director of Clinical Practice and Regulatory Affairs Texas Association for Homecare & Hospice