Pre-Claim Review Delayed Ahead of Florida Start Date

Amid reports that the rollout of the Pre-Claim Review Demonstration in Illinois led to a “complete mess,” the Centers for Medicare & Medicaid Services (CMS) will delay the start date in Florida by at least 30 days, the agency has announced. The decision comes as industry groups, home health care companies and two U.S. Senators have spoken out against the demonstration.

The pre-claim review requires home health care providers to submit claims to CMS contractors much earlier in the care process, for an audit before the claim is submitted for payment. The review was originally set to roll out in Florida no later than October 1, 2016. However, CMS will not begin the pre-claim demo in Florida as planned, and will announce a future start date with at least 30 days notice.

Home health care agencies in Illinois began the process August 3, and they will continue to be subject to the pre-claim audits.


“Based on early information from Illinois, CMS believes additional education efforts will be helpful before expansion of the demonstration to other states; therefore, we will not move forward with initiating the demonstration in Florida in October,” the agency stated on its website. “This education effort will focus on how to submit pre-claim review requests, documentation requirements, and common reasons for non-affirmation.”

The delay will also be effective for Texas, Michigan and Massachusetts, where pre-claim was originally scheduled to be implemented later this year and the beginning of 2017. The new start dates for these states and Florida have not been announced, though the agency stated it still expects a staggered start. CMS did not indicate if it would halt the demonstration in Illinois or take steps to aid in the pre-claim process beyond stepping up its education efforts.

“CMS views these efforts as crucial to the long-term success of the demonstration for beneficiaries, providers, and the Medicare program,” the agency stated.


The news should provide some relief for home health care agencies, which have been very vocal about about their concerns regarding the demonstration. However, the expansion of the demonstration will still likely move forward in the coming months.

“At this point we can only view it as a pause, albeit a very welcome one,” William Dombi, vice president for law at the National Association for Home Care & Hospice (NAHC), told Home Health Care News. “We also want to see [CMS] suspend [Pre-Claim Review] in Illinois. The project does not work and will not work no matter what CMS does. Whatever CMS is trying to fix with so called improper payments can be addressed more effectively and efficiently by other means that are more targeted.”

NAHC has advocated against implementation of pre-claim and recently scorned CMS and contractors for the problems reported in Illinois.

Another group, the Visiting Nurse Associations of America (VNAA), a national, non-profit industry organization that supports, advocates and promotes mission-driven community-based health care providers, has made challenging pre-claim expansion as one of its advocacy issues, with plans to educate Congress about its potential to overburden home health agencies.

While the demonstration has only been effective in Illinois since August 3, the implementation has not been successful, according to reports provided to HHCN. One agency reported none of its claims submitted for pre-claim review had been approved by the Medicare Administrative Contractor (MAC) involved.

One of the biggest concerns surrounding the demonstration is a requirement which mandates a physician’s signature be included in the pre-claim requests. While the face-to-face requirement is already a requirement, it can be a significant burden to secure the signature on a care plan so early on in the care process. The issue has the potential to delay care to patients, home health care agencies said during an open forum call with CMS in June. To quell concerns of providers, CMS stated at the time it would work on outreach with physicians for timely compliance.

CMS has said it will provide at least a 30-day notice before new start dates in Texas, Michigan and Massachusetts, as well as Florida.

Written by Amy Baxter

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