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Florida Members of Congress Question CMS about Prior Authorization Program

Posted on Friday, September 21, 2018 7:29 PM

Several members of Florida’s Congressional Delegation have sent a letter to CMS regarding the Review Choice Demonstration (RCD) detailing their concerns with the program. 

The RCD program was introduced to identify and reduce fraud in the Medicare home health benefit. The main differences between the two versions of prior authorization are the allowance for providers to opt for a post-payment review, or no review at all in the RCD. Providers that choose no review are subject to a 25 percent reimbursement reduction. CMS plans to launch the RCD in Illinois, Florida, North Carolina, Ohio, and Texas.

The Florida delegates are in support of measures aimed at decreasing fraud and abuse but are concerned that the RCD could have a negative impact on seniors and disabled Floridians that rely on home health services.  “Their concerns are based on the Illinois experience with PCR in 2016 and 2017. Specifically, they list out seven questions regarding the Illinois experience and what was learned, including: what types and incidences of fraud were discovered, how was patient access to home health affected, how did CMS use the PCR results in the RCD demo, and if other regulatory requirements (such as the face-to-face requirement) could be modified to reduce improper payments.”

Source: NAHC Report

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