CMS Wants to Revive Controversial HHA Claim Review Process

HHA preclaim review processThe Centers for Medicare & Medicaid Services (CMS) wants to revive a controversial demonstration project for Medicare fee-for-service home health that it says is designed to reduce fraud.

What was supposed to be a three-year project, starting in Illinois and expanding to several other states, including Florida, launched in 2016. The idea was for providers to participate in either pre-claim or post-payment reviews designed to detect and prevent fraud and abuse.

However, the project was suspended just before it was to expand to Florida after complaints from home health agencies that it was resulting in reduced access to care and increased burdens on their operations. Even federal lawmakers urged CMS to scrap the project and revamp it.

This week, CMS once again reversed its decision with a “revised” demonstration project that would move beyond Illinois into Ohio, North Carolina, Florida and Texas, with the option to expand to other states in the Palmetto/JM Medicare administrative contractor (MAC) jurisdiction.

Those that participate must agree to either 100 percent pre-claim review or 100 percent post-payment review.

“These providers will continue to be subject to a review method until the HHA (home health agency) reaches the target affirmation or claim approval rate. Once a HHA reaches the target pre-claim review affirmation or post-payment review claim approval rate, it may choose to be relieved from claim reviews, except for a spot check of their claims to ensure continued compliance,” according to CMS.

Those providers who do not wish to participate will receive a 25 percent payment reduction on all claims submitted for home health services and could still be reviewed by recovery audit contractors.

CMS is once again seeking public comment on the controversial demonstration project. The proposal is posted on the Federal Register and subject to a 60-day public comment period ending July 30.

The Health Law Offices of Anthony C. Vitale can help home health agencies navigate the every-changing healthcare landscape. If you have any questions about the demonstration project and how best to comply, contact us at 305-358-4500 or email us at

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