CHICAGO – U.S. Senator Dick Durbin (D-IL), along with the entire Illinois delegation, today called on the Centers for Medicare and Medicaid Services (CMS) to delay further implementation of the Pre-Claim Review Demonstration (PCRD) in Illinois, which has resulted in unintended consequences for patient access to care and provider capacity for Medicare home health services. Currently, between 60-80 percent of PCRD submissions in Illinois are being non-affirmed by the Medicare Administrative Contractor (MAC). This non-affirmation rate is leaving many patients without clarity on whether their medically necessary care will be covered. As a result of Illinois’ experience to date, CMS is delaying implementation of the pilot in Florida, Texas, Michigan, and Massachusetts.
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“Seven weeks into the PCRD, the experience of this pilot in Illinois has resulted in severe burdens on patient access to care and provider capacity. We urge CMS to delay further implementation of the PCRD in Illinois, which CMS has already announced they will do for other states,” wrote Durbin in a letter to CMS Acting Administrator Andy Slavitt.
When CMS first proposed to impose the mandatory home health prior authorization demonstration, Senator Durbin, along with Senators Nelson (D-FL) and Stabenow (D-MI) wrote to CMS to outline concerns about the broad scope of the demonstration, its impact on beneficiary access to services, and the potential impact on Medicare costs due to delays in medically necessary services and readmissions. CMS took into consideration some of these concerns regarding prior authorization and amended the demonstration accordingly. However, Illinois’ experience under the PCRD has been alarmingly burdensome for home health providers, which is harming patient access to care.
Durbin shares CMS’ interest in identifying Medicare fraud and reducing improper payments and has expressed a strong desire to continue working with CMS to address Medicare home health fraud, which a recent Department of Health and Human Services Inspector General report found was prevalent in Illinois. However, Durbin remains concerned that implementing the PCRD as presently structured – and without sufficient education and training – could jeopardize the delivery of care to beneficiaries in need.
