CMS introduces new Pre-Claim Review Demonstration proposal

Yesterday, the Centers for Medicare & Medicaid Services (CMS) announced a request for public comment on a new Pre-Claim Review Demonstration proposal. The new demonstration proposal offers home health agencies in the five proposed demonstration states three different options for payment. Under the new proposal, agencies can choose either potential full payment with pre-claim or postpayment reviews, or agencies can choose to forego the review process altogether with a 25 percent reduction in payments on all home health claims submitted. Agencies that choose the third option and payment reduction may still be eligible for review by Recovery Audit Contractors (RACs). The unpublished memo is currently available here, while the published version will appear on Thursday, May 31st in the Federal Register here.

The five states included in the new proposal are: Illinois, Ohio, North Carolina, Florida, and Texas. Ohio and North Carolina are new additions to the current proposal, replacing Massachusetts and Michigan in the original demonstration. The original demonstration did begin in Illinois in 2016 but was paused on April 1, 2017 and never re-started. At the time, CMS provided a brief Q&A on the pause here.

As in the past, the Alliance will be working with our membership as well as colleagues across the industry, to formulate a comment letter to CMS. You can read the Alliance’s comments to the Office of Management and Budget (OMB) from 2016 on the original PCRD proposal here. In those comments, the Alliance highlighted concerns related to the burden on home health agencies, process consideration, and legal authority.

CMS is said to be providing further updates this week so stay tuned for more information.

Alliance members interested in joining the discussion on PCRD and other regulatory and legislative efforts, as well as clinical and quality improvement should reach out to the Alliance’s Director, Policy Communications & Research, Jen Schiller at, to join the Alliance’s monthly Quality & Innovation Work Group.

Recognizing Mental Health Awareness Month at Home

Mental health awareness is critical in the delivery of health care at home. More than one in four home health care patients has a form of severe mental illness (SMI), defined by the Centers for Medicare and Medicaid Services (CMS) as having depression or other mental disorder, including bipolar disorder, schizophrenia, and other psychoses.

It can be easy to overlook the mental health of patients at times, especially given over 85 percent of Medicare home health patients have three or more chronic conditions and nearly one in three struggle with at least two different activities of daily living such as eating, dressing, or bathing.

Accounts of patients who receive mental health care through home health are few and far between, but their stories are reflective of so many others. Take for instance the story of Jane Early, BSN, who profiled a day on the life of a mental home health care nurse in the November/December 2017 edition of Home Healthcare Now. Early describes one patient with schizophrenia she had a number of years ago who was receiving in-home care following a hip replacement surgery. The first step was to visit the patient’s mental health clinic and then to do an assessment of the patient’s environment. Although the patient’s husband also faced mental health issues he was able and willing to be a support person, and the couple had extended family that was able to help address the environmental challenges in the home. Concluding her piece, Early declares, “When mental illness is part of the assessment, the importance of communication and education cannot be overstated.”

A few years back, the Alliance profiled Mr. John Cross, a Vietnam veteran receiving in-home care at an assisted care facility, who suffered from schizoaffective disorder. Mr. Cross was receiving home health care following an acute psychiatric hospital stay and the therapy interventions, which included occupational therapy, psychiatric nursing, and caregiver education, helped to manage some of the symptoms of schizoaffective disorder, including depressed episodes, periods of manic behavior, and impaired occupational function. Along with the help of the staff at the care home in which he was living, Mr. Cross’s sister was also an active provider of care for her brother. The program manager in Mr. Cross’s case echoed Early’s statements about the need for relationship building with the patient and support team.

Perhaps the most important takeaway from the profiles of mental health patients is the message that while patients with mental illness have unique needs, they’re ultimately no different than any other patient. In the Alliance profile above, Elizabeth Gregory, RN, CNS, PhD, Director of Behavioral Health at Amedisys, noted her concerns about inaccurate portrayals of mental illness, including the perception of a highly violent population. She clarified that these perceptions are untrue, and violent behavior is no more likely in the mental health population than in the general population. She stressed that patients with mental and behavioral health diagnoses are deserving of the same dignity and care as their peers.

As we begin to wind down Mental Health Awareness Month we hope to shine a light on of the work being done by home health care to address the particular needs of patients with mental illness. But they can’t do it alone. As both stories tell us, a patient’s additional support system, be it family and/or other caregivers, is a vital piece of the puzzle, especially when treating patients with mental illness.

We thank the providers and caregivers helping to care for patients with mental illness at home.