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The Centers for Medicare & Medicaid Services (CMS) pre-claim review demonstration project intended to heighten scrutiny of home health services is advancing into Florida, federal officials announced this week.

Calling home health “a critical part of the healthcare continuum” and “instrumental in helping a patient with Medicare benefits recover after an illness or injury,” CMS issued a fact sheet noting that the demonstration that began in Illinois on Aug. 3, 2016, will expand to the Sunshine State for episodes of care beginning on or after April 1, 2017.

The start dates for the remaining states participating in the demonstration – Texas, Michigan, and Massachusetts – have not yet been announced.

“Under this demonstration, physicians and clinicians enrolled in Medicare will continue to make healthcare decisions in coordination with their patients, including creating a care plan for the types of home health services a beneficiary needs,” CMS explained in the fact sheet. “Once home health services are ordered by a Medicare physician, eligible beneficiaries should be able to receive Medicare’s home health services immediately; the main change under this demonstration is that home health agencies will submit the supporting documentation prior to submitting the final claim for payment.”

Pre-claim review does not change beneficiary eligibility standards or Medicare’s documentation requirements for home health care, the agency added. Medicare will review the documentation to determine if coverage requirements for home health services are met and will issue a pre-claim review decision generally within 10 days. If the documentation submitted was insufficient, then the HHA (or beneficiary) may submit additional documentation to support the claim. Once sufficient documentation is submitted, Medicare is expected to make timely payment on the home health services claim following the standard process.

The reason for the increased scrutiny is obvious: In 2015, CMS said, home health claims had a 59-percent improper payment rate, and what the agency labeled a “large proportion” of the improper payment rate was due to insufficient documentation.

“The pre-claim review demonstration will, among other things, help educate (HHAs) on what documentation is required and encourage them to submit the correct documentation, while still allowing (them) to begin providing services,” CMS said. “It is also important to note that this demonstration does not change the process of submitting the Requests for Anticipated Payment (RAPs). A RAP is a split percentage payment approach to ensure adequate cash flow to (HHAs).”

CMS said the demonstration also “aligns Medicare’s payment requirements and approach with commercial insurers, including some Medicare Advantage plans.”

“A (HHA) may resubmit the supporting documentation as many times as necessary during the pre-claim review process. During the pre-claim review, Medicare will work closely with the (HHA) to explain what documentation is needed and why a prior submission was insufficient,” the agency announced. “Currently, the opportunity to fix home health documentation and resubmit a claim for payment is rare, and is typically only available in the administrative appeal process after a claim has been denied. The pre-claim review resubmission process helps (HHAs) successfully submit the necessary documentation before submitting a final claim for payment. This new process should decrease improper payments because of insufficient documentation, as well as reduce the need for HHAs) to appeal claims.”

If a pre-claim review request is ultimately not approved during the pre-claim process, then the final claim for payment will be denied, but the HHA may appeal that determination, CMS added. If the HHA fails to submit a request for pre-claim review, but the final claim is submitted for payment, the final claim will be subjected to a pre-payment medical review. If a final claim is never submitted, the standard procedures will be followed as it pertains to recouping the RAP payment, and in most cases, a beneficiary would not be liable for expenses in a home health claim that has been denied.

“Through this demonstration, CMS aims to test the level of resources required for the prevention of fraud instead of engaging in ‘pay-and-chase’ (strategies) and to determine the feasibility of performing pre-claim review to prevent payment for services that have high incidences of fraud,” CMS said. “We will have robust monitoring in place to make adjustments if needed and maintain prompt beneficiary access to care. This monitoring will include surveying some of the physicians that ordered home health services and some of the (HHAs) that provided home health services in the five states during the demonstration. We look forward to feedback and public input as we move forward with the demonstration.”

The news was met with a measure of disdain from the home health industry, as the National Association for Home Care & Hospice (NAHC) in its regularly published newsletter outlined what it said were “widely criticized” serious problems with the demonstration’s launch in Illinois.

“The rollout of the project in Illinois … triggered confusion, significantly increased paperwork burdens, high volumes of claim rejections, and irrational claim determinations,” wrote William A. Dombi, NAHC’s vice president for law.

Still, Dombi noted, CMS reported that in Week 18 of the Illinois project, the affirmation (acceptance) rate of pre-claim review submissions had reached 87 percent (that rate includes submissions that were originally rejected, but later affirmed on resubmission).

“It is believed that the vast majority of the ‘improper payments’ relate to issues with the physician certification and face-to-face documentation requirements,” Dombi wrote.

“NAHC and the state home care associations have been aggressively pursuing remedies for the problems caused by the project since its original unveiling in February. Since that point, numerous members of the House and Senate have raised concerns regarding the validity and efficacy of the project that uses a broad-brush approach, targeting all home health agencies in the state,” he continued. “Bipartisan legislation has been introduced that would stop the operation of the project and require CMS to submit a detailed report to Congress on the outcome of the project to date and options for alternative approaches.”

Coinciding with the CMS announcement that the demonstration was advancing into Florida, NAHC announced a five-step advocacy plan:

  1. Seeking a suspension/rescission of pre-claim review by the incoming Administration.
  2. Introduction of legislation to suspend pre-claim review in the upcoming 115th Congress in the House and Senate.
  3. Development of a lawsuit to challenge the legal validity of the project.
  4. Initiation of a major provider education effort.
  5. Establishment of standards for CMS to scale back the application of pre-claim reviews to target only high-risk providers and that rely on random sampling methodologies for pre-claim reviews overall in order to reduce unnecessary administrative burdens.   

Still, Dombi admitted, the Illinois experience has had what he called some “positive outcomes.”

“The most notable is that CMS has recognized that the complex task of claims reviews can lead to errors by its contractors,” he wrote. “In recent weeks, home health agencies in Illinois have received review affirmations on the types of cases that previously had been rejected for insufficient documentation. In addition, home health agencies have recognized their own documentation weaknesses and have taken corrective actions. NAHC believes that the lessons learned by all parties in Illinois can inform CMS to use much less burdensome remedial actions than pre-claim reviews with comparable results.”  



The CMS demonstration website can be found at https://www.cms.gov/Research-Statistics-Data-andSystems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Pre-Claim-Review-Initiatives/Overview.html.

Additional details on the pre-claim review demonstration for home health services can be found at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/MedicareFFS-Compliance-Programs/Overview.html; click on the tab titled “Pre-Claim Review Initiatives.”

The pre-claim review demonstration for home health services also will be discussed on an upcoming Special Open Door Forum call, which will be announced on the CMS website at http://www.cms.gov/OpenDoorForums.

Specific questions about the demonstration should be sent to HHPreClaimDemo@cms.hhs.gov. CMS will respond to these questions by posting more “Frequently Asked Questions” online at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/MedicareFFS-Compliance-Programs/Overview.html; click on the tab titled “Pre-Claim Review Initiatives.” 




Mark Spivey

Mark Spivey is a national correspondent for RACmonitor.com, ICD10monitor.com, and Auditor Monitor who has been writing and editing material about the federal oversight of American healthcare for more than a decade.

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