1. Cameron, Joy Mishell MPP

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The home healthcare industry is subject to a complex and duplicative set of the regulations that limit innovation and access to home care. Two of these programs, one a demonstration and the other a regulatory requirement, have significant documentation needs. They are:


* Pre-Claim Review Demonstration. This unnecessary regulation requires the full submission of a claim to be approved before the claim can be submitted. It is duplicative of other processes and does nothing to reduce fraud.


* Face-to-Face Documentation. This regulation was created by the Affordable Care Act to require a face-to-face encounter between a patient and a provider. The implementation of this provision has been deeply flawed and inconsistent and the impact on home healthcare agencies (HHAs) and beneficiaries has been profoundly negative.



Pre-Claim Review Demonstration

Under the guise of an attempt to eliminate "bad actors" and those who are not appropriately providing and billing for care, the Centers for Medicare and Medicaid Services (CMS) has a demonstration underway in Illinois, slated for Florida (April 1, 2017) and pending for Texas, Michigan, and Massachusetts.


This demonstration requires the completion of a "pre-claim," which is an extensive documentation form that has all of the characteristics of a normal home healthcare claim. The concern is that this form must be submitted prior to the final claim and receive a "provisional affirmation" in order for the final claim to not be penalized. The penalty for not submitting with a provisional affirmation is 25% of the total cost of the claim. Further, on average, it takes a registered nurse, who is familiar with the pre-claim process an average of 57 minutes to complete the initial submission and an hour and fourteen minutes to complete subsequent resubmissions.


VNAA continues to be greatly concerned and frustrated with the impending Pre-Claim Review Demonstration for home healthcare services. The Paperwork Reduction Act Notice used to implement the Pre-Claim Review Demonstration notes as the justification for the demonstration "extensive evidence of fraud and abuse in the Medicare home health program, in particular, in the chosen demonstration states."


Despite these clear and appropriate characteristics of fraudulent activity, Dr. Shantanu Agrawal, Deputy Administrator and Director of the CMS Medicare Integrity Program Office, stated in his May 24, 2016 testimony before the U.S. House of Representatives Committee on Energy and Commerce that the majority of the 59% of improper payments were because of poor or incomplete documentation (Agrawal, 2016). Repeatedly, the home healthcare industry is shamed by reports of "improper payment rates" and denials of payment to agencies.


The Pre-Claim Review Demonstration is a blunt policy instrument that targets all providers and puts a disproportionate burden on good actors. At the same time, nothing in the pre-claim process will stop bad actors from submitting falsified claims; pre-claim programs have no mechanism to identify these bad actors.


Face-to-Face Documentation

In the year prior to the start of Face-to-Face, the improper payment rate for home healthcare was about 17.3% for 2013 and following the implementation of Face-to-Face; 51.4% in 2014 and 59% in 2015 (U.S. Department of Health and Human Services, 2013, 2014, 2015).


The "face to face" documentation regulations are unclear and much is left to interpretation. Adding a layer of complexity to the scenario, the Medicare Administrative Contractors (MACs) have differing views on how to interpret these requirements and guidance is applied regionally, not universally. Minor aspects like using particular forms or not, stamping them "face to face documentation" or not, numbering pages as 1 of X, versus just sequential numbering-have all been reasons for "improper payments." VNAA and the home healthcare industry have worked with Congress to clarify and improve these regulations, but action has not happened yet.


If the home healthcare record could be used to substantiate the physician's record in documentation-"shall be used" instead of "may use," which the MACs have interpreted as they do not have to allow it-much of the "improper payments" due to "incomplete or poor documentation" would no longer be valid and the improper payment rate would drop. This would be a victory for both the home healthcare agency and CMS.


A Note of Waste, Fraud, and Abuse

VNAA supports a wide range of policies to combat waste, fraud and abuse, and our members are committed to improving the integrity of the Medicare Home Health Program. VNAA has strongly endorsed home healthcare moratoriums, outlier caps, and other data-driven tools that are effective at stemming fraud in a targeted and direct manner. The Health and Human Services Office of the Inspector General recently identified five key characteristics for home health fraud (Office of Inspector General, 2016)


* High percentage of episodes for which the beneficiary had no recent visits with the supervising physician


* High percentage of episodes that were not preceded by a hospital or nursing home stay


* High percentage of episodes with a primary diagnosis of diabetes or hypertension


* High percentage of beneficiaries with claims from multiple HHAs


* High percentage of beneficiaries with multiple home healthcare readmissions in a short period of time



VNAA continues to stand ready to work with CMS to develop commonsense safeguards and indicators to allow for data-driven, targeted review and enforcement.




Agrawal S. (2016). Medicare and Medicaid program integrity: Combatting improper payments and ineligible providers. Retrieved from[Context Link]


Office of Inspector General. (2016). Nationwide analysis of common characteristics in OIG home health fraud cases. Retrieved from[Context Link]


U.S. Department of Health and Human Services. (2013). Supplementary appendices for the Medicare fee-for-service. Retrieved from[Context Link]


U.S. Department of Health and Human Services. (2014). Supplementary appendices for the Medicare fee-for-service. Retrieved from[Context Link]


U.S. Department of Health and Human Services. (2015). Supplementary appendices for the Medicare fee-for-service. Retrieved from[Context Link]