CMS announces ‘pre-claim review’ of home health providers

Woman holding clipboard

The Centers for Medicare and Medicaid Services will conduct pre-claim reviews for home health providers in Illinois beginning Aug. 1, and filter the demonstration project out to four additional states over the course of the next six months, according to an announcement made last week.

The announcement comes less than four months after CMS proposed a stricter preauthorization pilot project for home health providers in the same five states, a proposal that was met with resistance from the home health industry along with more than 100 members in the U.S. House of Representatives

Unlike a preauthorization program, a pre-claim review begins “after services start but prior to the final claim being submitted,” according to a Q&A posted by CMS. In addition to Illinois, the demonstration project will be unveiled in Florida, Texas, Michigan and Massachusetts, all of which show “extensive evidence of fraud and abuse in the Medicare home health benefit.”

“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,” according to the CMS announcement.

The Partnership for Quality Home Healthcare remains steadfastly opposed to the project. In a statement, the coalition of acknowledged the transition to a pre-claim review alleviates concerns about limiting access to home health services, but argued the project “creates new challenges for home health agencies in providing seamless, integrative high quality skilled health care.”

For more:
- read the CMS announcement
- here’s the CMS Q&A
- see the Partnership for Quality Home Healthcare statement

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