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NAHC Cites Program Integrity Contractor Issues in Recent Letter to CMS

Posted by Crystal Parks on Nov 8, 2013 7:53:16 AM


Bill Dombi, Vice President for Law for the National Association for Home Care & Hospice (NAHC) recently sent a letter to the Centers for Medicare & Medicaid Services (CMS) regarding the practices of one of their Program Integrity contractors that is, “using coverage standards that do not exist and clearly violate the law.”

The letter, sent this week via email to one of CMS’ policy advisors, details the issues that NAHC has with this particular CMS Program Integrity contractor – whose egregious misunderstanding or misrepresentation of the Medicare home health benefit has, “entirely warped and re-written longstanding Medicare home health coverage policy.”

The letter sent by Mr. Dombi details some of the most concerning issues with the Program Integrity contractor, stating that:

“The letter [sent by the contractor to HHAs] states that, “the program has never been intended for on-going treatment of long-term, chronic disorders.” This statement conflicts with 42 CFR 409.44(b)(2)(iii). That rule was put in place in the early 1990s as part of the settlement of Duggan v. Bowen. The regulatory standard was also reaffirmed in the recent settlement in Jimmo v Sebelius… This contractor is way off base and exposes CMS to another round of litigation if a correction in their policy understanding is not immediate.

[The Program Integrity contractor] also says that the benefit “has always been intended for patients who have been recently released from a medical facility...” This seriously incorrect statement raises questions as to how this contractor was ever selected in the first place and how they could still be doing work for CMS.  

Adding to the matter is its statement that the benefit is only of “short-term nature” as “underscored” by the certification period being restricted to 60-day episodes…” They are inventing benefit standards that have never existed.”

“As stated in the letter,” said Mr. Dombi, “NAHC believes that immediate and in-depth corrective action must be undertaken with this contractor. If an HHA was so off base in its understanding of Medicare coverage standards, it would be visited by the OIG, FBI, and Department of Justice. We hope that there will be a swift resolution to this issue, but if CMS is unable or unwilling to do so, we will have no choice but to consider other avenues to correct the actions of this contractor.”

To view a copy of the Program Integrity letter, please click here.

From the NAHC Report article



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