NAHC Submits Comments on Prior Authorization Proposal to CMS

The National Association for Home Care & Hospice (NAHC) recently submitted comments to the Centers for Medicare & Medicaid Services (CMS) on the Medicare Prior Authorization of Home Health Services Demonstration. In its comments, NAHC urged CMS to withdraw the proposal, which would institute a system of “prior authorization” on all home health services in five states (see previous NAHC Report articles here and here).

“NAHC has long partnered with Medicare and other payers in rooting out the fraud, waste, and abuse through creative policy changes,” NAHC stated in its comments. “However, the proposed prior authorization project falls short of what it takes to be an effective program integrity tool sufficient to offset the down-side risks to Medicare beneficiaries and upstanding home health agencies. For the reasons stated above, NAHC respectfully recommends that CMS withdraw its proposal for prior authorization in home health services.”

NAHC detailed several concerns with the proposal including that it would be costly, burdensome, and ineffective. In addition, NAHC stated that CMS lacks the legal authority and justification for imposing it on home health agencies.

There is no legal authority for the proposed PA demo. The proposal does not comply with the congressionally expressed authority for a demonstration program of this nature. Congress has limited the use of prior authorization to certain items of Durable Medical Equipment (DME). Any proposal to implement a prior authorization system must be promulgated through formal rulemaking.

The proposed prior authorization project is overbroad, untargeted, administratively costly, and would be ineffective in curbing any fraud. “Prior authorization is partly in use in Medicare Advantage plans and a few state Medicaid programs. NAHC members report one common consequence—delayed admission of the patients into home health services,” NAHC stated in the letter. Overall, the agencies report high administrative costs accompanied by continual detours from providing care to undertaking efforts to convince a remote person with the payer to authorize care.”

There are better tools to address Medicare home health risk areas. “CMS has the data capabilities to laser target program integrity measures to identified high risk situations rather than rely on broad-based, random, shotgun-like measures such as prior authorization,” NAHC stated. “Accordingly, CMS should take advantage of this capability to the fullest extent.”

Medicare beneficiaries and providers must be given full due process. “In the event that CMS decides to move forward with consideration of prior authorization, it is essential that CMS provide an accelerated and robust appeal process for providers and beneficiaries. The absence of an authorization is a certain roadblock to care access,” NAHC stated.

The Proposed Prior Authorization Project Does Not Meet Program Integrity Standards Of Value. NAHC outlined standards of value for program integrity measures and concluded that the proposed project:

  • is not sufficiently targeted to the fraud or abuse of concern;
  • is not evidence-based with demonstrated return on investment;
  • does not prevent fraud;
  • is absent adequate legal authority;
  • erects barriers to appropriate care access;
  • would be excessively burdensome;
  • fails to distinguish between fraud and unintentional noncompliance;
  • would be highly likely to lead to a significant number of “innocent victims” through care delays, extended stays in high risk settings and wrongful rejections of authorization.

To view NAHC’s comments, click here.