A new bill introduced in the U.S. Senate would direct CMS to “reset” home health payment rates after years of permanent cuts under PDGM behavioral adjustments. The measure also includes several fraud enforcement measures meant to target bad actors without ensnaring legitimate home health providers.
 
The Medicare Home Health Payment Integrity and Protection Act (S.B. 5250) was introduced by Sens. Susan Collins, R-Maine, and Sen. Marsha Blackburn, R-Tenn.
 
“When billions of dollars are improperly siphoned from the Medicare home health program, this can undermine the integrity of the payment system used to reimburse legitimate providers and threaten care for the seniors who depend on it,” Collins said in a statement introducing the bill.
 
In applauding the legislation, The National Alliance for Care at Home noted it would correct flaws in CMS’ calculations for Medicare rate updates. Since PDGM was introduced in 2020, CMS has made payment cuts it attributes to behavioral changes by the industry tied to PDGM. Stakeholders have challenged these cuts and stress that bad data submitted by fraudulent providers has skewed the formula and cost legitimate agencies.
 
“This bill corrects longstanding flaws in home health reimbursement and takes a meaningful step toward a home health benefit that is stable and built for how care is delivered today. We strongly support the bill for its payment reforms, as well as measures to protect patients and preserve the integrity of the Medicare home health benefit.” said Jennifer Sheets, CEO of the Alliance, in a statement.
 
Beyond the payment reforms, the act would beef up policies and spending around fraud enforcement in home health. According to Collins, the act would:
  • Require that the identity of home health administrators be verified before agencies are enrolled and authorized to provide services;
  • Require proof of liability insurance for agencies that exhibit high risk of fraud;
  • Provide CMS with the authority to determine the factors that indicate that an agency presents an extreme risk of fraud, and to impose heightened screening requirements on such agencies;
  • Require much more frequent surveys of newly enrolled home health agencies, agencies that undergo ownership changes and agencies that reactivate their billing privileges;
  • Increase inspections of home health agencies that fail to submit quality data to CMS, or that engage in practices that are aberrant or signal fraudulent behavior;
  • Increase financial penalties for failing to report quality data;
  • Require accrediting agencies that work with CMS to meet or exceed CMS standards;
  • Require CMS training of home health surveyors for accreditation purposes;
  • Establish ongoing CMS oversight of accrediting organizations and provide CMS with authority to terminate deficient accreditors;
  • Authorize funding for CMS and federal law enforcement agencies for the investigation and prosecution of organized home health fraud schemes;
  • Authorize funding for CMS and its state agency partners to conduct accelerated surveys, enrollment validation, unannounced site visits, and operational verification of home health agencies; and
  • Provide CMS with rulemaking authority to carry out its provisions and require it to report to Congress.
LeadingAge welcomes the effort to address fraud, according to a statement from president and CEO Katie Smith Sloan.
 
“This bill’s oversight provisions are reasonable, appropriately targeted policies that would help maintain the benefit’s integrity,” she said. “Those, along with the important proposed payment changes, will help to ensure support for legitimate providers — including our nonprofit and mission-driven members.”