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CMS Pauses Home Health Pre-Claim Review, Won't Expand Demonstration

Published by Inside Health Policy
Michelle M. Stein
March 31, 2017

To the delight of home health providers, CMS on Friday (March 31) announced it has paused the home health pre-claim review demonstration for at least 30 days in Illinois, and will not expand the program to Florida in April. The National Association for Home Care and Hospice said CMS Administrator Seema Verma had requested a meeting with providers to hear about the problems with the program, and home health stakeholders met with the new CMS chief days before CMS' announcement.

CMS indicated that in the future, pre-claim review will be an optional process for home health agencies, according to NAHC. The group added that they expect those that use pre-claim reviews will be exempted from the risk of post-pay audits as long as there are no indications of fraud.

Also, in the next few weeks CMS intends to initiate a more targeted approach to pre-claim reviews that will focus on the first episode of care, certain diagnoses and home health agencies that don't have a high enough compliance rate, according to NAHC.

The group says it explained to CMS that the demonstration was finding paperwork errors rather than fraud, and more effective solutions are available to correct those errors. NAHC and the Partnership for Quality Home Healthcare want to work with CMS to develop alternatives to the pre-claim review demonstration.

“We are incredibly pleased CMS listened to the concerns expressed by bipartisan lawmakers and home health stakeholders, and suspended the application of the demonstration,” said Keith Myers, chairman for the Partnership for Quality Home Healthcare, in a statement. “While the Partnership fully supports CMS’ intent to reduce waste, fraud and abuse within the Medicare home health benefit, the pre-claim review demonstration is not the right approach and we are grateful CMS has chosen to suspend the program while improvements are made, which we believe will be beneficial to providers, physicians and patients alike.”

CMS has “opened up the lines of communication to consider policy changes” to documentation policies, as well, NAHC says. The group also expects face-to-face reform legislation to be introduced as early as next week.

“PCRD has demonstrated that the home health community needs to step up its efforts to achieve responsible levels of compliance with paperwork and documentation requirements in Medicare,” the NAHC post says. The group adds that it will be working on this in the coming months.

Last year, CMS indicated in a Paperwork Reduction Act notice that it was interested in subjecting home health claims in five “high risk fraud states” -- Florida, Texas, Illinois, Michigan and Massachusetts -- to prior authorization. Home health companies and some beneficiary advocates criticized that proposal, and a bipartisan group of 116 House lawmakers asked CMS to scrap it. CMS later announced it would implement a pre-claim review program rather than prior authorization. The agency said the pre-claim review program addressed lawmakers concerns, but HHS Secretary Tom Price, as a member of the House, had worked on legislation to delay the demonstration for a year.

The pre-claim review demonstration started in Illinois last August, and was set to expand to Florida in April. CMS says it has paused the program in Illinois, and contractors will not accept pre-claim review requests from the end of March through the end of the pause. The agency also said it will not expand the program to Florida on April 1.

“During the pause, home health claims can be submitted for payment and will be paid under normal claim processing rules. CMS will notify providers at least 30 days in advance via an update to this website of further developments related to the demonstration,” CMS says in a post on the agency's website.

Click here to see the original article on the Inside Health Policy website.

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