What CMS Should Do Instead of Home Health Pre-Claim Reviews

If there is a single criticism that summarizes all the complaints about the CMS document that misrepresents early Home Health Pre-Claim Review results in Illinois, it is this. The decision to publish spin instead of fact is a tacit admission by the bureaucrats at CMS that they know Pre-Claim Review is failing. If it were working as it should, they would have released a truthful report.

Unfiltered evidence from Illinois (see our report on the CMS document and NAHC response) shows that the pilot is being operated haphazardly by PGBA and that, even if it were well-run, its design ensures that it could never slow the activities of home health criminals. What it does is create the appearance that CMS is "doing something" about the fraud problem. This keeps Congress and MedPAC happy, as long as they do not look too closely at program details to see how poorly it was designed and how badly its poor design is being executed by PGBA.

CMS has always had the support of the healthcare at home sector for its stated desire to eliminate fraud, but has been met with nothing but dismay over its frequent decisions to punish every provider instead of taking the trouble to identify the bad ones. This lazy way out may be easier to design and implement but it is ineffective, in fact, counter-effective. It results in the suffering of honest providers and their patients while doing nothing to stop those who would stop at nothing to protect their fraud-driven incomes.

The overwhelming majority of providers who are simply trying to care for patients, provide jobs, and remain compliant would much rather see their tax money used to identify and eliminate the criminals from our midst than another misguided program that destroys the businesses of more honest than dishonest providers.

Therefore, CMS should immediately:

1. suspend pre-claim in Illinois
2. delay start dates in the other four states for at least a year
3. turn its attention to guaranteeing that Medicare Administrative Contractors properly train their pre-claim reviewers

During the delay, CMS should make an effort to identify the tiny minority of agencies generating all the fraud — paying kickbacks to referrers, purchasing lists of Medicare numbers, and submitting claims for services never performed — and then design a workable pre-claim program just for them. They are out there. They are easy to find. All they need to do is ask the good guys who they are.

Timothy J. Rowan, Editor, Home Care Technology Report

?2016 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan's Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. [email protected]