CMS puts HHA pre-claim review process on hold in Florida, other states

Plans by the Centers for Medicare & Medicaid Services (CMS) to begin a pre-claim review process for home health services have been put on hold for now. The demonstration program was to launch this month (October) in Florida and Texas, but CMS announced a postponement, noting that additional education efforts were needed before moving forward.

As we wrote about previously, CMS announced implementation of the three-year program for home health services in Illinois, Florida and Texas beginning this year and in Michigan and Massachusetts beginning next year. It started in Illinois on Aug. 3, before CMS determined additional education was needed.

The education effort will focus on how to submit pre-claim review requests, documentation requirements and common reasons for non-affirmation. CMS noted that those HHAs that have submitted requests for episodes of care that began prior to Aug. 3 will either be allowed to have the requests withdrawn or processed as test requests.

CMS is testing whether pre-claim review improves methods for the identification, investigation, and prosecution of Medicare fraud occurring among home health agencies providing services to people with Medicare benefits.  Additionally, CMS also is testing whether the demonstration helps reduce expenditures while maintaining or improving quality of care.

Although CMS has not stated so directly, there have been widespread reports in Illinois of significant disruptions and technical failures during the claims submission process, as well as inappropriate care denials.

CMS cited the need for the pre-claim demonstration because of a 59 percent improper payment rate among home health claims in 2015. A large proportion of the improper payment rate was because of insufficient documentation.

“Through this demonstration, CMS aims to test the level of resources required for the prevention of fraud instead of engaging in “pay and chase†and to determine the feasibility of performing pre-claim review to prevent payment for services that have high incidences of fraud,†CMS previously noted.

CMS has not stated when the program will be implemented except to say it will provide at least 30-days notice on its website. Once it is ready to begin re-implementing the demonstration process, CMS expects to stagger the start dates in the different states, beginning with Florida.

If you have any questions about the process and how to remain in compliance, contact the Health Care Offices of Anthony C. Vitale. We can be reached at 305-358-4500 or email us at info@vitalehealthlaw.com.