The Centers for Medicare & Medicaid Services (CMS) is implementing a three-year Medicare pre-claim review demonstration for home health services in the states of Illinois, Florida, and Texas beginning in 2016, and in the states of Michigan and Massachusetts beginning in 2017. CMS is testing whether pre-claim review improves methods for the identification, investigation, and prosecution of Medicare fraud occurring among Home Health Agencies (HHAs) providing services to people with Medicare benefits. Additionally, CMS is also testing whether the demonstration helps reduce expenditures while maintaining or improving quality of care.
The Pre-Claim Review demonstration does not create new clinical documentation requirements. HHAs will submit the same information they currently submit for payment, but will do so earlier in the process. This will help assure that all relevant coverage and clinical documentation requirements are met before the claim is submitted for payment. This demonstration should not delay care to Medicare beneficiaries and does not alter the Medicare home health benefit. The pre-claim review request may be submitted at any time before the final claim is submitted and can occur after home health services have begun.
HHAs will beging submitting pre-claim review requests in: Illinois beginning no earlier than August 1, 2016; Florida no earlier than October 1, 2016; Texas no earlier than December 1, 2016; and Michigan and Massachusetts no earlier than January 1, 2017. This demonstration that will end in all the states on June 30, 2019. If HHAs in the demonstration states do not utilize the pre-claim review process, those claims submitted for payment will be stopped for prepayment review and may be subject to denial. After the first three months of the demonstration in a participating state, CMS will reduce payment by 25 percent for claims that are deemed payable but did not first receive a pre-claim review decision.
Come hear about the new Home Health Pre-Claim Review (PCR) 3-Year Demo at these important one-day education events hosted by the Provider’s Association.
Listed below are the locations and dates of the Pre-Claim Review and Oasis C-2 workshops being held:
Please click on the location of your choice for more information.