CCJRM Threatens Home Health with Prior Authorization

CCJRM Threatens Home Health with Prior Authorization

The Comprehensive Care for Joint Replacement Model that begins April 1, 2016 is a CMS demonstration that proposes to adopt prior authorization processes and bundle home health reimbursement with the acute care hospitalization costs.

Prior Authorization

A Center for Medicare Advocacy (CMA) statement today warns home health providers that:

". . .This demonstration would undoubtedly negatively impact access to the home health benefit for many Medicare beneficiaries who live in the affected states.

"Requiring prior approval for every prospective home health recipient in a state for the provision of critically important services that help keep people in their homes rather than institutions, often when they are at their most medically vulnerable, will effectively delay and deny home health coverage for countless Medicare beneficiaries."

What if an agency, without prior authorization, provides home care to a beneficiary in a state where CMS' demonstration requires participation in the CCJRM?

  • If the documentation is complete “but all relevant Medicare coverage requirements are not met” the contractor will advise that Medicare will not pay for the treatment, and any claim submitted will be denied (subject to appeal). 
  • If the claim is determined to be payable, the agency will be penalized with a 25% payment reduction.

Homebound Confusion

Comprehensive Care for Joint Replacement Model threatens home health benefit further by including incomplete information about homebound status, the CMA warns further that "providers, contractors and the general public are far more likely to rely on (the abbreviated version of coverage rules in MLN Matters articles and Transmittals) than the actual language of the statue and regulations."

Descriptions of homebound status in documents relevant to the CCJRM exclude the two-criteria standard as well as exceptions that allow homebound patients to leave home under certain circumstances, even though doing so is difficult for them.

"History has shown that when descriptions of coverage rules in the statute, regulations and sub-regulatory guidance become more narrowly interpreted over time, misunderstandings and misinterpretation flourish, usually to the detriment of Medicare beneficiaries.  Short-cuts are taken and rules of thumb are established until the more restrictive criteria become the new, de facto, criteria in making coverage decisions. 

"Once a constriction of actual coverage rules is accepted as true, it is very difficult to rectify. The (Medicare Advocacy) Center urges CMS, providers, contractors and the general public to abide by the complete legal definition of “homebound” and to allow individuals who appropriately qualify for Medicare home care benefits to receive their needed care."

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