Home Health Pre-Claim Review Demonstration CMS Teleconference June 28

Put this on your calendar so you won't miss this opportunity to better understand CMS' pre-claim review demonstration. Even if your agency isn't in one of the demonstration states, these pre-claim reviews are relevant to individual agencies' compliance programs.

CMS will host a special Open Door Forum (ODF) call for home health agencies, physicians, and other interested parties to learn and ask questions about the home health services pre-claim review demonstration.  The call is Tuesday, June 14, 2016 at 2:00 – 3:00pm ET .  For more information and ODF updates, visit CMS at http://www.cms.gov/OpenDoorForums.

The Centers for Medicare & Medicaid Services (CMS) is implementing a three-year Medicare pre-claim review demonstration for home health services in 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 to identify, investigate, and prosecute Medicare fraud occurring among Home Health Agencies (HHAs) providing services to people with Medicare benefits.  Additionally, CMS is 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. Agencies will submit the same information they currently submit for payment, but 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 HHA (or the beneficiary) may submit a pre-claim review request after a Request for Anticipated Payment (RAP) is submitted by the HHA.  The pre-claim review process must occur within the first 30 days after a RAP is processed and before the claim is submitted by the HHA. The HHA will be providing services to the beneficiary during this time period.  

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.  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.

CMS will host a special Open Door Forum (ODF) call for HHAs, physicians, and other interested parties to learn and ask questions about the home health services pre-claim review demonstration.  The call is schedule for 2:00 – 3:00pm ET on Tuesday, June 14, 2016.  For more information and ODF updates, visit our website at http://www.cms.gov/OpenDoorForums.

For additional information please refer to the download sections below.

Questions about this demonstration may be sent to HHPreClaimDemo@cms.hhs.gov.