CMS Plans to Renew Home Health Pre-Claim Review

By Kristin Easterling

(May 30, 2018)—Following last week’s release of the Government Accountability Office (GAO) report on prior authorization, CMS released a memo on a new version of the controversial home health pre-claim review program. The memo details plans to resume the program in Illinois, Ohio, North Carolina, Florida and Texas, with the option to expand into other states in the Palmetto/JM Medicare administrative contractor (MAC) jurisdiction.

Background
The original version of pre-claim review rolled out in Illinois in August 2016. Providers in the industry protested the demonstration, citing poor administration of claims and lost revenue. Agencies in Illinois feared having to close their doors. The demonstration halted indefinitely prior to expanding to Florida in early 2017, amid the controversy and stakeholder pushback.

New Details
Under the new demonstration, agencies would be able to submit to either pre-payment or post-payment reviews or take a 25 percent payment reduction on claims submitted without a review. Those claims submitted without a review may be eligible for review by recovery audit contractors.

The memo has not been filed in the Federal Register as of press time, but at that time, CMS will be seeking public comment, with a 60-day deadline after filing.

William A. Dombi, president of the National Association for Home Care and Hospice (NAHC) said, “The CMS proposal to resurrect the pre-claim review demonstration program is of great concern to the home health community. While it is touted as a choice of options for home health agencies, the options presented are two with increased paperwork burdens and one that would financially cripple a home health agency with a 25 percent payment reduction. We certainly do not want to see nurses, therapists and homecare personnel spending their days chasing down paperwork at the expense of patient care.

“We are currently evaluating the new proposal and analyzing the data on the impact of the earlier iteration in Illinois with particular emphasis on patient impact. Further, we want to work with CMS to explore the alternatives that we presented to the Administrator in early 2017 as we believe those alternatives would be equally effective with much less administrative burden. Also, we are anxious to review the forthcoming details of the proposal that are due out on Thursday and intend the fully participate in the formal comment process.”

The full memo may be found here.

For a review of the 2016 demonstration, click here.