CMS to initiate Medicare home health pre-claim review in five states

The Centers for Medicare & Medicaid Services yesterday announced a pre-claim review demonstration for all Medicare fee-for-service home health services in Illinois, Florida, Texas, Michigan and Massachusetts. Start dates will be determined in the coming months, but will be no earlier than Aug. 1 in Illinois, Oct. 1 in Florida, Dec. 1 in Texas, and Jan. 1 in Michigan and Massachusetts, the agency said. Under the three-year demonstration, the home health provider, billing entity or beneficiary will be encouraged to submit to the relevant Medicare Administrative Contractor a request for pre-claim review, along with relevant documentation, within 30 days of the beneficiary’s first treatment and before submitting the final claim. The MACs are expected to communicate to the home health agency and beneficiary a decision provisionally approving or disapproving payment within 10 business days. After the first three months of a state’s demonstration, claims submitted without a pre-claim review will undergo a pre-payment review and receive a 25% payment reduction if approved. Last month, 116 members of the House of Representatives urged CMS to withdraw a proposed demonstration for prior authorization of home health services in the same states after AHA opposed the proposal. “We are very concerned that CMS chose to move forward with this demonstration project,” said Joanna Hiatt Kim, AHA vice president for payment policy. “A more appropriate approach would have been to target only those home health agencies with likely fraudulent activities. Instead, this demonstration will burden a wide swath of providers and potentially reduce access to needed care for beneficiaries.”