AMA blasts role of physicians in proposed prospective payment


HHBR Washington Correspondent

WASHINGTON – The American Medical Association (AMA; Chicago) is warning the Health Care Financing Administration (HCFA; Baltimore) that the agency’s proposed prospective payment system (PPS) may lead to underutilization of home care services.

Specifically, the AMA argued that it is "extremely inappropriate" for physicians to be tasked with approving a home health agency’s home health resource utilization group (HHRG) for each patient. "The AMA is adamantly opposed to this proposal," the association asserted in its recent comments submitted to HCFA.

According to the AMA, the physician’s role in home care is to establish a plan of care and approve and certify medical necessity. While that aspect is within the physician’s expertise, the association argues that it would be inappropriate for doctors to be saddled with the additional responsibility of "essentially auditing and verifying" the accuracy of the HHRGs selected by home health agencies. "Physicians provide medical care," said the association. "They are not auditors nor law enforcement officials."

The AMA argued that it is not even feasible for physicians to approve HHRGs and said it is unclear how the new system would work. "Physicians are not on-site at the home health agency and cannot adequately monitor the home health agency HHRG designation. Moreover, the association pointed out that it is the home health agency and not the physician that completes the OASIS form used to submit the claim. Physicians do not see or even have access to the OASIS form and should not be held responsible for the assignment of HHRGs, the AMA argued.

According to the AMA, physicians are already forced to comply with thousands of pages of Medicare regulatory requirements. "It is incredible that HCFA would propose, on top of all these responsibilities, that physicians be required to learn and audit the administrative billing system for home health agencies to which they refer patients," the association declared. "Such a requirement might even serve as a disincentive to physicians to refer patients for home health services."

Like the national home care associations, the AMA also voiced its concern that HCFA’s proposed split payment ratio may cause cash flow problems and that its proposed outlier policy may threaten patient access and quality of care.

The AMA also contends that the methodology and data used to develop the proposed PPS are inadequate and unreliable and urged HCFA to consider the PPS an interim system for three years as it makes refinements.