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CMS Proposed Pre-Claim Review Demonstration for Home Health Services

The Centers for Medicare & Medicaid Services (CMS) recently published an information collection notice regarding its proposed Pre-Claim Review Demonstration (Demonstration) for home health services. The Department of Health and Human Services (HHS) Secretary is authorized to create or demonstrate improved methods to investigate and prosecute fraud in the provision of care or services in Social Security Act established health programs. Accordingly, CMS aims to develop and implement a Medicare demonstration project to determine whether pre-claim reviews would help CMS improve its methods for identification, investigation, and prosecution of Medicare fraud among Home Health Agencies (HHAs) that provide services to Medicare beneficiaries. In this notice, CMS seeks public comments on its new proposal which improves upon the related 2016 Demonstration for home health providers. In 2016, CMS implemented the Demonstration for Home Health Agencies (HHAs) in five states (Illinois, Florida, Texas, Michigan and Massachusetts). The 2016 Demonstration was intended to be a three-year program; however, policymakers and industry groups expressed concerns that it impacted health care costs and delayed patient access to care, causing CMS to pause the Demonstration in 2017. CMS aims to use the public comment period to identify and avoid similar issues in the revised Demonstration.

Medicare Pre-Claim and Post-Payment Reviews

Under the revised Demonstration, CMS offers providers with two choices related to their claims review to demonstrate their compliance with CMS’s home health policies. Providers may participate in either 100 percent pre-claim review or 100 percent post-payment review, a significant change from the 2016 Demonstration which only allowed pre-claim reviews. For those providers that choose to forgo both review options, they will receive a 25 percent payment reduction on all claims submitted for home health services and may be eligible for Recovery Audit Contractor reviews. Further, providers will remain subject to a review method until the HHA reaches the target affirmation or claim approval rate. Once the pre-claim review target affirmation rate or post-payment review claim approval rate is reached, providers can opt out of claims reviews and accept a spot check to ensure continued compliance. CMS proposes to implement the new Demonstration in Illinois, Ohio, North Carolina, Florida, and Texas, with the potential to expand to other states in the Palmetto/JM jurisdiction.

The Demonstration proposal is presented in the Federal Register with a 60-day public comment period. All comments are due by July 31, 2018.

The CMS Notice is available at:

https://www.gpo.gov/fdsys/pkg/FR-2018-05-31/pdf/2018-11492.pdf.

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