CMS Floats New Version of Pre-Claim Review for Home Health

The Centers for Medicare & Medicaid Services (CMS) is seeking public input on a new proposal that would bring back the controversial pre-claim review process for home health Medicare claims.

Under the new program, home health agencies (HHAs) could choose to undergo either pre-claim or post-payment reviews, or to forgo reviews but take a 25% payment reduction on all claims submitted for home health services, CMS explained in a memo issued Tuesday.

“These providers will continue to be subject to a review method until the HHA reaches the target affirmation or claim approval rate,” the document states. “Once a HHA reaches the target pre-claim review affirmation or post-payment review claim approval rate, it may choose to be relieved from claim reviews, except for a spot check of their claims to ensure continued compliance.”


CMS proposes to roll out the reviews in Illinois, Ohio, North Carolina, Florida and Texas, with the option to expand to other states under the jurisdiction of Medicare Administrative Contractor (MAC) Palmetto/JM.

The effort is intended to ensure proper payments and flag any activity that could indicate Medicare fraud. The proposal will appear in the Federal Register in the coming days, at which point it will be subject to a 60-day public comment period.

This would be CMS’ second attempt at a pre-claim review program for home health. The first rolled out in Illinois in August 2016. It was widely decried within the industry, as home health agencies protested that it placed huge burdens on them and was poorly administered, choking their cash flow and threatening the viability of their businesses. Pre-claim fallout included merger and acquisition activity grinding to a halt, and federal lawmakers intervening on behalf of beleaguered providers.


The program was paused indefinitely just before it was set to take effect in its second state, Florida.

Written by Tim Mullaney

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