Compliance Update: Proposed Prior Authorization Pilot

Last month, we reported that prior authorizations were proposed as a method of combatting fraud and abuse in home health by CMS.  Well, it has caught the attention of many agencies across the country and many have been quite vocal in opposing this new proposal.

The pilot program, if implemented, will run in 5 states: Florida, Texas, Illinois, Michigan, and Massachusetts.  Each of these states has a historically high level of home health utilization and recently, have all had incidents of high instances of fraud.  Four of the five states currently have active teams trained to detect, identify and prosecute Medicare fraud full time.

The proposal, while intended to reduce fraud, would actually harm agencies that are compliant and operating as they should.  Many stakeholders have commented that CMS should be going after known agencies who have a pattern of committing fraud and have been allowed to continue to do so.  It’s not uncommon to hear about an agency being reported to a state regulatory body for improper practices, only to fall on deaf ears with no action taken.
So if the government wants to focus on fraud, the government should focus on its own internal processes for handling allegations of such fraud before placing the whole industry on a lockdown.  Instead of using common sense, the government is once again using regulation to punish all participants rather than singling out those known, consistent abusers.