Pre-Claim Review Suspended

WASHINGTON, D.C. (September 20, 2016)—The Visiting Nurse Associations of America (VNAA) today commended the Centers for Medicare & Medicaid Services’ (CMS) decision to delay implementation of the Home Health Pre-Claim Review Demonstration to additional states including Florida, which was originally scheduled for October 1. CMS’s announcement follows repeated warnings from home health leaders and bipartisan lawmakers that the Pre-Claim Review Demonstration needs additional review and clarity before CMS expands to other states, as planned.

“We commend CMS for taking time to address the problems experienced in Illinois, and to offer further outreach and education on a program that has been fraught with misinformation and confusion for providers and the patients receiving care under the Medicare home health benefit,” said Tracey Moorhead, CEO and President of VNAA. “While VNAA agrees that home health agencies, physicians, patients and Medicare Administrative Contractors in Illinois should receive additional education and support, we strongly believe that immediate suspension of Pre-Claim Review in Illinois is the more prudent approach.”

In its announcement, CMS stated that additional education efforts are needed to ensure the program’s success and that it will not move forward with initiating Pre-Claim Review in other states until more education can be provided to improve overall understanding of the pre-claim review submission process, documentation requirements and reasons for non-affirmation.

Since the Illinois rollout began on August 3, providers across the state have experienced significant disruptions and technical failures during the claims submission process due to difficulty using the Medicare Administrative Contractor’s (MAC) electronic submission system. Others have reported inappropriate care denials. In light of these events, VNAA calls on CMS to provide relief to Illinois’ home health providers and patients by extending to them the same delay that has been granted to the other states affected by this demonstration.

“VNAA continues to believe that Pre-Claim Review for home health services is not the most effective approach for reducing Medicare fraud or abuse and should be discontinued,” added Moorhead. “Instead, we will continue encouraging CMS to collaborate with us to develop program integrity reforms to remove bad actors from the Medicare home health program in a strategically targeted and data driven manner.”

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