NAHC: Pre-Claim Review Makes No Sense, Goes Too Far

Days away from the start of the pre-claim review demonstration in Illinois, industry groups are pushing back yet again.

The National Association for Home Care & Hospice (NAHC) recently submitted harsh comments to the Office of Management and Budget (OMB) over the pre-claim pilot program by the Centers for Medicare & Medicaid Services (CMS). The demonstration is set to begin in five states—Illinois, Florida, Michigan, Texas, and Massachusetts—periodically over the next year, with Illinois beginning on August 1, 2016.

CMS has stated that the demonstration is aimed at reducing fraud. However, the downsides of the program to home health care companies are concerning for the industry, NAHC argued in its statements.


“The proposal is untargeted, with high administrative costs and operational burdens, is likely to create improper barriers to access to timely care, would not be effective against the fraud concerns in Medicare home health services, and would not aid in achieving a higher degree of compliance with the alleged claim documentation deficiencies,” NAHC wrote.

The industry backlash to the pre-claim demonstration has been strong since the proposal first appeared on the Federal Register at the beginning of 2016. Home health agencies argue the program will have too high an administrative burden, and have already challenged CMS officials on their ability to process the additional requirements in a timely manner and their own ability to secure proper documentation from physicians.

NAHC went even further by questioning the legality of such a demonstration program, citing that the nature of this demonstration does not comply with CMS’ authorities to investigate and prosecute fraud.


The association also expressed doubt at CMS’ estimated costs of the demonstration. While CMS maintains the project will cost nearly $300 million over three years, NAHC says the actual costs could exceed $1 billion if claims are submitted multiple times as allowed.

NAHC has recommended that OMB instructs CMS to withdraw the proposal for prior authorization altogether.

Written by Amy Baxter

Companies featured in this article: