Federal Lawmakers Are Collecting Data Regarding Pre-Claim Review to Present the Results to Congress

Posted on Tuesday, September 27, 2016 10:29 PM

While CMS’ announcement of delaying the Pre-Claim Review Demonstration in Florida, Texas, Massachusetts and Michigan was great news, Illinois is still feeling the wrath of the program since it’s still underway there.

Agencies in Illinois have voiced their concerns about high denial rates on their claims submissions, discrepancy in the pre-claim process and administrative burdens.

Illinois is desperate for help and wondering what the lawmakers are doing in response to this situation. Especially since both U.S. Senators from Florida, Ben Nelson (D) and Marco Rubio (R), sent a letter to CMS speaking against the Pre-Claim Review before the delay was even announced.

“Since the decision by CMS to delay it for all other states but Illinois, there has been some response [from lawmakers] this week, but nothing coordinated yet in Illinois,” Micah Roderick, director of public policy at the Illinois Homecare & Hospice Council (IHHC), told Home Health Care News. “We are hoping and waiting at this point.”

“Senator Durbin is aware of the issues around the implementation of the pre-claim review demonstration in Illinois and working toward a solution,” said a spokesperson from Durbin’s office. “Senator Durbin expressed his initial concerns in a letter to CMS this spring prior to the start of the demonstration, and CMS changed its original proposal in response to the issues we raised. We are currently collecting information and data regarding the impact of the demonstration on patients and providers, and have been, and will continue to be, in touch with CMS to ensure continued patient access to medically necessary, cost-effective services while maintaining program integrity.”

“Sen. Kirk joined a bipartisan letter in April expressing concern over this demonstration,” a spokesperson told HHCN. “Based on CMS response and concerns over patient access to care, Kirk is asking CMS to scale back the demonstration. Efforts to improve Medicare program integrity are critical to the fiscal future of our country, but shouldn’t come at the expense of vulnerable seniors that need and prefer the comfort of their own homes.”

Rep. Tammy Duckworth (D-IL) also stated her concern about the issue.

“Congresswoman Duckworth has and will continue to work with her colleagues to ensure that the nearly 200,000 Illinoisans who depend upon skilled home health services through Medicare can continue receiving the care they need and deserve,” Ben Garmisa, communications director for Duckworth, told HHCN. “The Congresswomen is concerned with reports that the pre-claim review demonstration could negatively impact care and put patients at risk, and she is seeking additional information regarding implementation problems. She will keep pushing to ensure CMS takes these concerns, which she shares with patients and providers alike, into account as it works to reduce fraud and waste.”

Both lawmakers stressed their continued efforts to work with CMS on this issue.

“It’s hard to find words right now,” Roderick said. “It’s just so bad. It’s puzzling why CMS is looking at their own data and not stopping [the program]. But we’re also waiting for that data.”

“VNAA continues to believe that Pre-Claim Review for home health services is not the most effective approach for reducing Medicare fraud or abuse and should be discontinued,” Tracy Moorhead, CEO and president of VNAA, said in a statement.
IHHC encourages all home health agencies to continue voicing their opinions with the issues they are experiencing with the demonstration in Illinois.

“Our message is that we’ve got to keep it up,” Roderick said of the response from home health agencies in Illinois. “Providing data on how this is affecting the patients and providers themselves is what we really need in order to show Congress, who has really yet to act together, that this is a very serious situation here in Illinois.”

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