Home Health Line: Florida Association Seeks Congressional Relief From MA Pain

By Burt Schorr, Home Health Line

The visit authorization delays and denials home health agencies long have experienced in serving Medicare Advantage (MA) enrollees show no signs of going away. But a new letter from the Home Care Association of Florida (HCAF) to a key senator aims to provide relief for the ever-worsening situation.

Home health executives are finding themselves forced to invest more and more hours in getting the information and authorizations plans require. Indeed, plans’ coverage reductions and delayed authorizations effectively have restricted beneficiary access to quality home care, the HCAF noted in its recent letter to Sen. Bill Nelson, D-Fla., chairman of the Senate Aging Committee.

What effect the letter will have is unclear. For now, the Senate Aging Committee staff is working with the association to get more information about the role of third-party administrators (TPAs) in authorizing services, committee and HCAF staffers tell HHL. (For steps agencies can take on their own to minimize MA risk, see p. 5.)

The services TPAs perform for individual plans vary, but they can include utilization management, creden- tialing of home health networks, management of claim payments and quality improvement programs. Utilization management, the primary irritant for agencies, involves “evaluating the appropriateness, medical necessity and efficiency of healthcare service requests,” says CareCentrix, a leading third-party administrator headquartered in East Hartford, Conn., on its website.

Agencies share MA frustration

The letter includes the Medicare Advantage experiences of 30 agencies in Florida, Texas, Indiana, Minnesota and Illinois. One example: A 400-patient agency in New Port Richey, Fla. that has contracted with eight MA plans finds itself owed $54,000 for visits one of those plans disputes, with small chance of being reimbursed. “With more and more seniors on those policies and less on Medicare, we had no choice,” the agency’s owner told the Florida association.

“It’s not just [that] the negotiated rates they pay us per visit are terribly low. It’s also the administrative overhead it costs us to get the authorizations, then to submit every piece of paperwork they request and then fight with them when they tell us we didn’t submit a note for one day,” the owner complained. Earlier this year, in fact, the agency started to refuse referrals from physicians “that use our agency only for Medicare Advantage patients,” the owner noted. “If I didn’t do that, we might not be able to survive another year.”

CMS, for its part, declined comment on the HCAF complaints.

Discharge notice is a challenge

Another problem is how to provide patients with the advance notice of discharge Medicare requires. One Phoenix-area agency’s physical therapists decided a plan enrollee recovering from hip replacement surgery would be ready for discharge after four more physical therapy visits. But the plan’s TPA ruled that additional visits weren’t justified, relates the agency’s administrator, who asked not to be identified because the TPA controls plan payments for a third of her Medicare patients.

To give the patient an opportunity to appeal the plan’s denial, the agency had to cover the cost of a final visit itself. The patient won the appeal, but gained just one more therapy visit, the administrator says. Indeed, a few of her patients had their discharges overturned on appeal as often as three times before their home health needs were satisfied, she notes.

While plans’ Medicare contracts oblige them to provide enrollees with all the services fee-for-service Medicare covers, CMS generally lets plans decide the number of visits per episode a home care patient should receive, notes Mary Carr, associate director for regulatory affairs with the National Association for Home Care & Hospice.

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