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Baby Steps toward Program Integrity

Yesterday, CMS imposed a temporary moratorium on enrollment of new “home health agencies in designated geographic locations to prevent and combat fraud, waste and abuse.” The areas affected by the announcement include four metropolitan areas (Fort Lauderdale, Detroit, Dallas and Houston) and extended earlier moratoria in Detroit and Dallas.

These moratoria are necessary and supported by ample evidence of high ratios of agencies to patients; higher than normal payments; and extreme variations in service utilization when compared to other counties across the country.

However, a moratorium on new agencies is not sufficient. These moratoria serve simply to dissuade unscrupulous operators from opening new agencies in these counties. More important, moratoria on new agencies do not address the hundreds of existing agencies in these counties, and others, which merit closer regulatory oversight and auditing.

CMS should instead focus regulatory oversight and contractor auditing on these areas and on agencies suspected of program fraud and abuse. Currently, CMS takes a broad-brush approach to regulatory oversight that allows and encourages CMS contractors to be far too punitive on the majority of good agencies who provide high quality services for patients, including vulnerable and complex populations. Many of these agencies lack the resources to respond to auditor requests for hundreds of patient records over several years. Agencies confronted with these demands for record production are often forced to remove needed personnel from the field and from patient care, thus impacting patient access to needed services.

Yes, MedPAC repeatedly expresses concerns about the growth in number of home health agencies in certain areas of the country. Temporary moratoria can address that issue. However, moratoria imposed to simply limit new agencies will not be successful in addressing current fraud and abuse.


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