Comment and response document

CMS Response to Public Comments Received for CMS 10406

The Centers for Medicare and Medicaid (CMS) received comments from two (2) home health agencies. This is the reconciliation of the comments.

Comment:

Comment received from Stephanie Henchey, Springhill, FL 34608.

CMS-10406Medicare Probable Fraud Measurement Pilot; CMS-10599. In representing a small home healthcare agency in Florida servicing 300 patients a month I feel it is essential to speak on this proposed measure of prior authorization for Home Health Services. We care for patients that come from a variety of different payer sources so we have firsthand working knowledge of what it takes to admit and maintain Home Health patients. There are some key points that must be considered: 1. Patients are coming out of the Hospital with a much higher acuity level

1. HHAs and referring physicians will be forced to redirect staff time away from clinical beneficiary care and support to instead comply with additional, onerous and duplicative administrative requirements.

2. CMS will be forced to devote considerable resources to develop and manage an untargeted national program instead of devoting appropriate resources to fraudulent providers easily identified by existing fee-for-service claims data.

3. CMS will create another barrier to innovation in Medicare by imposing additional administrative burdens on agencies instead of supporting programs that reduce hospital admissions and readmissions or identify value-added opportunities for community-based home health services.

Response:

CMS appreciates your comment regarding the Medicare Probable Fraud Measurement Pilot. Healthcare fraud is of a concern in the Medicare program and the cause of large financial losses for the government. There are many estimates regarding the rate of fraud but never a valid estimate. This study will provide CMS with the accurate information to CMS officials to better evaluate the success of ongoing fraud prevention activities.

Comment:

Comment received from Enny Simmons , Centura Health at Home

In reference to identify and target fraudulent home health agencies (HHAs)—additional data collection is not needed. We oppose this pilot program for the following reasons:

• The vast majority of current improper payments are due to documentation issues (namely, face-to-face) rather than fraud.

• Collection of information from an unquantified “random national sample” of HHAs, referring physicians AND beneficiaries is not realistic, will significantly raise administrative costs and provide little to no return in the form of improved patient care and outcomes.

• HHAs and referring physicians will be forced to redirect staff time away from clinical beneficiary care and support to instead comply with additional, onerous and duplicative administrative requirements.

• CMS will be forced to devote considerable resources to develop and manage an untargeted national program instead of devoting appropriate resources to fraudulent providers easily identified by existing fee-for-service claims data.

• CMS will create another barrier to innovation in Medicare by imposing additional administrative burdens on agencies instead of supporting programs that reduce hospital admissions and readmissions or identify value-added opportunities for community-based home health services.

Response:

CMS appreciates your comment regarding the Medicare Probable Fraud Measurement Pilot. However a valid rate of fraud is non-existent. The sample that CMS will use for this study is a valid random sample. This study will provide CMS with the necessary information so officials can better evaluate the success of ongoing fraud prevention activities.