Prior Authorization Demo Proposed by CMS

Piling on top of existing pilots and demonstrations, the Centers for Medicare and Medicaid Services have released another proposed program that would establish Medicare prior authorizations and a fraud measurement pilot.

Massachusetts is one of five states – along with Florida, Texas, Illinois and Michigan – selected for the prior authorization demonstration. There are no details on what the authorizations would entail in the proposed demonstration aside from CMS stating that it would be similar to “Prior Authorization of Power Mobility Device (PMD) Demonstration, which was implemented by CMS in 2012.” The rule continues that “this demonstration would also follow and adopt prior authorization processes that currently exist in other health care programs such as TRICARE, certain state Medicaid programs, and in private insurance.”

CMS’ reasoning for implementing such a program a belief that it will help assist in “developing improved procedures for the identification, investigation, and prosecution of Medicare fraud occurring among HHAs providing services to Medicare beneficiaries.”

According to CMS, Medicare contractors will request the information from home health agency providers submitting claims for payment from the Medicare program in advance to determine appropriate payment.

The second piece of the CMS’ proposal is titled the “Medicare Probable Fraud Measurement Pilot.” The pilot would establish a baseline estimate of probable fraud in Medicare fee-for-service payments for home health care.

CMS purports that this would be accomplished using, at least in part, a summary of the service history of the HHA, the referring provider, and the beneficiary to estimate the percentage of total payments that are associated with probable fraud and the percentage of all claims that are associated with probable fraud for Medicare fee-for-service home health.

HCA is currently working to get more details on this demonstration so as to devise an advocacy strategy.

Comments on the proposed demonstration are due by April 5th and details are available here on the Federal Register.

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