Section 1 Short title
This Act may be cited as the “Pre-Claims Undermine Seniors’ Health Act of 2016” or the “PUSH Act of 2016”.
Pre-Claims Undermine Seniors’ Health Act of 2016
A BILL
To delay the Medicare demonstration for pre-claim review of home health services, and for other purposes.
Sec. 2 Delay in the Medicare demonstration for pre-claim review of home health services
In general— In the case of the demonstration for pre-claim review for home health services furnished under title XVIII of the Social Security Act for operation in 5 States under section 402(a)(1)(J) of the Social Security Amendments of 1967 (42 U.S.C. 1395b–1(a)(1)(J)), as announced in the Federal Register on June 10, 2016 (81 Fed. Reg. 37598)—
in the case of any of such 5 States in which the demonstration began operation before the date of the enactment of this section, the Secretary of Health and Human Services shall suspend the operation of the demonstration in such State so it does not apply to episodes of care beginning earlier than the later of—
1 year after such date of enactment; or
6 months after the date that the Congress receives the report submitted under subsection (b);
in the case of any of such 5 States not described in paragraph (1), the Secretary shall delay any operation of the demonstration in each State so it does not apply to episodes of care beginning earlier than the later of—
1 year after the earliest date that such demonstration was scheduled to begin operation in the State as so announced; or
6 months after the date the Congress receives such report; and
in the case of a State not described in paragraph (1) or (2), the Secretary shall not begin operation of such a demonstration in the State until at least the later of—
1 year after such date of enactment; or
6 months after the date that the Congress receives such report.
Report— Not later than 1 year after the date of the enactment of this Act, the Secretary shall submit a report to Congress on Medicare pre-claim review of home health services. The report shall include at least the following:
A comprehensive analysis and description of the impact of Medicare pre-claim review of home health services in any State in which it had been implemented before the date of the enactment of this Act, including its impact on Medicare beneficiaries, home health agencies, physicians, and Medicare administrative costs and the data described in paragraph (5).
A detailed description of the resources used by home health agencies, physicians, and the Department of Health and Human Services and its contractors in conducting such pre-claim review.
A description of alternative measures that can be taken to identify the nature of improper payments in Medicare home health services, the root cause for such improper payments, and possible corrective actions (other than the use of pre-claim review) that can be taken.
Detailed data on the claims subject to, and the result of, Medicare pre-claim review conducted before the date of the enactment of this Act, including the following:
The number of pre-claim submissions and resubmissions.
The percentage of responses to such submissions and resubmissions that—
fully approve (or affirm) such services;
fully disapprove (or non-affirm) such services; or
do not fully approve (or affirm), or fully disapprove (or non-affirm), such services.
Changes in utilization of and spending on Medicare-covered home health services, inpatient hospital care, and skilled nursing facility services.
The number of home health agencies in States where such pre-claim review occurred.
The average dollar amount per claim and aggregate amount involved in such reviews, based on the types of responses described in subparagraph (B).
The 50 diagnosis codes that were most frequently subject to review.
The proportion of cases subject to review that were post-acute care.
The impact of the review on patient access to home health services.
The impact of the review on the continuity of care, including the proportion of cases that result in a disruption or delay in patient care.