[Updated] Pre-Claim Paused in Illinois, Delayed in Florida

One day before the Pre-Claim Review Demonstration (PCRD) was set to begin in Florida, the program has been put on pause, the Centers for Medicare & Medicaid Services (CMS) announced Friday.

The pause could preface major changes to the demonstration, including the possibility it will become optional for home health participants, one major industry association revealed.

The demonstration will be put on hold for at least 30 days in Illinois, beginning April 1, 2017, and will not expand to Florida as scheduled on April 1, CMS announced Friday, March 31.


“During the pause, home health claims can be submitted for payment and will be paid under normal processing rules,” CMS stated on its website Friday.

The agency stated it would provide an update to providers via its website at least 30 days in advance of further developments related to the demonstration.

The announcement comes on the same day the agency submitted a proposal to delay the effective date of the new home health Conditions of Participation (CoPs) by six months.


PCRD has become a controversial demonstration, with a delay last year. It has been underway in Illinois since August 2016 and was originally scheduled to roll out to four other states—Florida, Texas, Massachusetts and Michigan.

Industry groups were largely ecstatic over the news on Friday afternoon and expressed gratitude for the pause. The push for a pause of the program was an effort by many, including lawmakers in affected states, home care associations and providers.

“We are incredibly pleased CMS listened to the concerns expressed by bipartisan lawmakers and home and home health stakeholders, and suspended the application of the demonstration,” Keith Myers, chairman for the Partnership for Quality Home Healthcare and co-founder and CEO of home health care company LHC Group (Nasdaq: LHCG), said in a statement. “While the Partnership fully supports CMS’ intent to reduce waste, fraud and abuse within the Medicare home health benefit, the pre-claim review demonstration is not the right approach and we are grateful CMS has chosen to suspend the program while improvements are made, which we believe will be beneficial to providers, physicians and patients alike.”

While CMS did not announce if it would make changes to the program Friday, the Home Care Association of Florida (HCAF) was bullish CMS will “drastically change the focus and design of the current PCR demonstration project.”

“For months, industry leaders have advocated tirelessly to delay PCR so that access to high quality, cost-effective care is not interrupted for patients,” Kyle Simon, director of government affairs and communications at HCAF, told Home Health Care News. “Today, we’ve achieved that goal and we are grateful. We look forward to working with national industry partners, Florida home care providers and federal policy makers to reform this demonstration so it effectively protects the Medicare home health benefit.”

Reforms ahead

The National Association for Home Care & Hospice (NAHC) stated its first-hand knowledge that the program will undergo significant changes on Friday. NAHC was one of several home health parties that met with the new CMS administrator, Seema Verma, earlier in the week.

“In our meeting with the CMS administrator, it was indicated that CMS will be reforming the PCRD demonstration,” the association wrote in an article to its members. “Going forward, CMS will make pre-claim review an optional process for home health agencies. Those HHAs that use PCR will be exempted from the risks of post-pay review absent any indications of fraud.”

CMS is also intending to reform the demonstration to a more targeted approach, “focusing on the first episode of care, certain diagnoses and HHAs that do not demonstrate a sufficient level of compliance performance,” according to NAHC. The current demonstration broadly targets the five states with some of the highest rates of improper payments.

Specifics of the revised program will be initiated in the coming weeks.

Senator Marco Rubio (R-FL) was similarly grateful for the news Friday. He was among other lawmakers, including Senator Bill Nelson (D-FL), who iterated home health concerns over the program to CMS.

“I appreciate the administration taking our concerns into account, and I’m encouraged by CMS’s decision to delay the Home Health Pre-Claim Review Demonstration from taking effect April 1st,” Senator Rubio said in a statement to HHCN. “It’s my hope this process ultimately results in a better program that more effectively targets fraud.”

Written by Amy Baxter

Photo Credit: “Welcome to Florida,” by Paul Hamilton, CC BY 2.0

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