LeadingAge recently responded to CMS’s second Request for Information (RFI) on the Patients Over Paperwork initiative. The initiative, first launched in 2017, aims to reduce unnecessary burden, increase efficiency, and improve the beneficiary experience by streamlining regulations and subregulatory guidance. CMS has received over 3,000 comments since that time, classified into nine categories. Our comments, available here, contributed as follows:

Documentation Requirements

LeadingAge highlighted the burden of documentation requirements that are excessive and duplicative. We discussed the burden of forms that only serve to duplicate information found elsewhere in a beneficiary’s medical record, such as the Pre-Admission Screening and Resident Review (PASRR) form used in nursing homes, as well as the burden of excessive documentation requirements, such as those required to obtain prior authorization from a Medicare Advantage plan for home health services.

Quality Measures and Reporting

We encouraged CMS to reconsider quality measures and quality reporting to adopt measures that were meaningful, patient-centered, and aligned across payment programs and provider types. We emphasized how the quantity of quality measures on which nursing homes, hospitals, and home health providers report presents a barrier to quality improvement when efforts are spread across 30 measures. We illustrated how measures such as the long-stay antipsychotic usage measure for nursing homes can stand in the way of patient-centered care when they do not consider the unique needs of an individual. We further discussed the disservice of such a quality measure when measurements and data are not specific to the identified problem.


LeadingAge continued advocacy on interoperable health information systems. The burden required to integrate information between providers and the detrimental impact on beneficiaries whose providers do not have access to a holistic view of their care was underscored in the example of home health face-to-face documentation requirements. We further urged CMS to include aging services providers in health information technology initiatives and to include aging services providers in technical assistance programs and activities designed to assist in the adoption of electronic health records and interoperability in rural settings.

Provider Participation Requirements

In accordance with our long-standing concerns, LeadingAge took this opportunity to discuss the burden resulting from inconsistencies in the survey and certification processes. This issue seems particularly prevalent among skilled nursing facilities, as evidenced by the data we referenced that shows the average number of deficiencies ranging from 3 to 14 deficiencies depending on the state. We acknowledged that CMS is working to address this issue and recommended joint surveyor-provider education programs, demonstrated competency requirements, and the implementation of a surveyor credentialing system.

Audits and Claims

Referring to the 3-day qualifying stay required for skilled nursing eligibility, we urged CMS to eliminate the inpatient status distinction from this requirement and allow all time spent in the hospital to qualify toward the 3-day qualifier. We also recommended CMS reevaluate claims policies and processes related to Medicare Advantage plans. We shared feedback from members who report that claims are often denied erroneously, payment is recouped for prior-authorized services, and third-party utilization management companies require more documentation than the actual Medicare Advantage plan, resulting in even greater administrative burden.

We noted in our comments that while the examples provided referred specifically to nursing homes and home health, they were examples of more pervasive issues and encouraged CMS to explore how strategies might be employed to address the issue across provider types.