Home Health Medicare Pre-Claim Review: The Good, the Bad and the Ugly

The Pre-Claim Review Demonstration, a recent Medicare home health pilot program from the Centers for Medicare & Medicaid Services (CMS), is one of many new requirements that home health agencies across the country could have to adopt depending on the outcome of recent actions being taken by industry organizations, stakeholders and Congress to extend the delay or withdraw it altogether. Created to enforce a more proactive oversight strategy on Medicare home health coverage in an effort to reduce fraud and abuse, the pre-claim review’s pilot phase was to begin with implementation in Illinois, Florida and Texas in 2016, then Michigan and Massachusetts in 2017—all states with soaring fraud, abuse and over-spending rates.

But since the Illinois implementation in August, the National Association for Home Care & Hospice (NAHC) has described the demonstration as “a complete mess,” after impacts in the pilot state are reportedly “highly negative” and “rife with problems.” These adverse reports prompted Florida Senators Ben Nelson (D) and Marco Rubio (R) to push for a delay in Florida implementation—the next state set to begin the demonstration on October 1. After urging for a delayed expansion “until CMS, stakeholders and Congress have the opportunity to evaluate and understand the impact of the demonstration in Illinois,” CMS announced an indefinite delay on pre-claim review while they focus education efforts on how to submit pre-claim review requests, documentation requests, documentation requirements and common reasons for nonaffirmation.

While the next pilot states are on hold for now—CMS will announce further expansion with at least 30 days’ notice—the demonstration remains in effect in Illinois. And as NAHC and other stakeholders continue the fight to suspend Illinois’ pre-claim review mandates, many agencies in other states are worried CMS will instead resume expansion.

The Good The intent of the demonstration is good and meant to ensure home health services are funded by Medicare only when criteria for service coverage is met. When successful, this would result in the reduction of improper payments and the cost of additional documentation and resources it takes for CMS to chase them.

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