After false starts, restarts, postponements, and more than a little pushback from APTA and other stakeholders, CMS is ready to once again roll out a home health agency (HHA) payment program in Illinois that would force HHA providers in the state to participate in preclaim or postpayment reviews—or choose a third option that would involve "minimal" postpayment review but cut payment by 25%.
Called the "Review Choice Demonstration for Home Health Services," the program will require HHAs in Illinois to choose 1 of 3 program options: submit documentation for 100% of Medicare patients while they are receiving care (a "preclaim review"), submit 100% of all claims for a postpayment review, or opt for "minimal" postpayment review and swallow a 25% payment cut. HHAs can begin making their choice on April 17 but must submit a final decision to CMS by May 16. The system will begin on June 1.
If parts of the system sound familiar (particularly to HHAs in Illinois), that's because they are: CMS first introduced the project in Illinois in 2016, with plans to roll out the system to 4 additional states in 2017. In the face of criticism from most HHA organizations about the excessive burden of the demonstration, CMS put the brakes on the rollout. In June 2018, CMS announced that it would move ahead with a revised demonstration in 5 states—but then held off again and announced that once the delay was over, the program would begin in Illinois.
According to CMS, the 3-option system will serve as a kind of audition for HHAs, which, after 6 months of compliance, would be allowed additional choices including "relief from most reviews except for a review of a small sample of claims." The demonstration is intended to offer more flexibility and choice for providers, as well as reward providers who show compliance with Medicare home health policies.
APTA staff and members of the Home Health Section submitted extensive feedback to CMS on the demonstration as it was being considered and reconsidered—and considered again. Like many other stakeholders that provided comments to CMS, APTA argued that the program was excessively burdensome and could decrease patient access to care.
With the demonstration program ready to begin, many HHAs are wondering the same thing: will the program be expanded to other states and, if so, when?
"At this point, it's nearly impossible to say how or if CMS will move to expand this system," said Kara Gainer, APTA director of government affairs. "Although some tweaks were made to the project, we believe it's still based on a flawed approach that could put unsustainable pressure on some HHAs. We will closely monitor the demonstration as it plays out in Illinois and take every opportunity to press CMS for significant improvements before it's applied to other states."