Home Health Pre-Claim Review Starts Two Days Late

Home health care agencies in Illinois should not submit pre-claim review requests for episodes of care that began prior to Aug. 3, 2016, the Centers for Medicare & Medicaid Services (CMS) announced Thursday.

The controversial pre-claim review demonstration was scheduled to begin on Aug. 1, but was delayed by two days “to allow time to resolve an administrative procedural requirement,” CMS stated in an announcement posted online and emailed to providers.

The short delay may seem minor, but considering that many home health agencies already are deeply concerned or outright opposed to the pre-claim review, this immediate wrinkle is likely to increase their apprehensions.


Industry leaders have pushed CMS to hit pause on the program, saying that the manpower needed to carry it out is lacking, and that providers could experience crippling problems if their payments are unduly delayed as a result of the review process.

But CMS has stood by its plans to roll out the program, under which providers in select states must submit their claims for review to Medicare Administrative Contractors (MACs), who will deem them proper or send them back to be resubmitted if problems are detected. CMS frames the demonstration as a way of getting a tighter handle on reimbursements in an industry riddled with improper documentation, fraud, and abuse; providers say it is not an effective way to root out problems and bad actors.

Illinois is the first state to begin participating. Florida is next in line to participate, starting no earlier than Oct. 1, 2016.


“The revised start date does not impact demonstration requirements or processes, and the demonstration will be operationalized as planned for episodes of care starting on or after August 3, 2016,” CMS stated. “CMS’ Medicare Administrative Contractors will work directly with any HHAs that submitted requests for episodes of care that began prior to August 3, 2016 and allow them to either have the requests withdrawn or processed as test requests.”

Written by Tim Mullaney

Photo Credit: “Calendar” by Dafne Cholet, CC BY 2.0

Companies featured in this article: