CMS Proposes Pre-Claim Start Date, EVV Implementation Survey

The Patient-Driven Groupings Model (PDGM) has dominated the home health industry’s regulatory conversations of late, which is understandable, as it’s likely the biggest policy shift from the Centers for Medicare & Medicaid Services (CMS) in the past few decades.

There are several other regulatory items flying under the radar, however, including the potential reincarnation of the widely decried pre-claim review demonstration.

The home care space also faces significant regulatory change, including in the implementation of the electronic visit verification (EVV) requirement, which was mandated by the 21st Century Cures Act for 2019 but has since been delayed.


CMS announced updates to its revised pre-claim review proposal, intended to reduce Medicare fraud and improper claims, last week. The agency then followed up that news with EVV-related updates on Friday.

First revealed in May, the new pre-claim iteration targets Illinois, Ohio, North Carolina, Texas and Florida. It’s similar to the controversial roll out of pre-claim review from 2016, but with some differences.

Unlike CMS’ 2016 pre-claim test, for example, the new version gives home health agencies the option to forgo prior authorization in favor of post-payment review. Both models let providers completely opt out of the process, as long as they agree to take a 25% reduction on all payments for claims submitted. Under the new version, home health agencies with high claims approval rates could skip full review and only take part in a spot-check to ensure continued compliance.


At a basic level, EVV requires home care providers to verify type, date, location and duration of a home care service provided through the use of mobile applications and other methods.

Comment window expanded, start date identified

CMS announced last week it hopes to launch the demonstration in Illinois on December 10 of this year.

The revised pre-claim review demonstration would help assist in developing improved procedures for the identification, investigation and prosecution of potential Medicare fraud, according to CMS. Additionally, the demonstration would help make sure that payments for home health services are appropriate, the agency noted.

The initial test of pre-claim review also took place in Illinois, with many agencies reporting paperwork delays, staffing challenges and inconsistencies in working with Medicare Administrator Contractors (MACs). In fact, some agencies even reportedly had to add positions or redirect nurses from caregiving to paperwork duties just to deal with pre-claim review requirements.

CMS also announced that it was expanding public commenting opportunity for industry stakeholders by adding a second window, which will last 30 days until October 29. CMS received less than 470 public comments during its first 60-day feedback window, which officially closed at the start of August.

“I have experienced pre-claim review firsthand in Illinois,” an anonymous commenter from Illinois wrote during the first comment period. “It was a disaster.”

CMS pushes for EVV survey

President Donald Trump signed H.R. 6042, a bill to delay the nationwide deadline for EVV in Medicaid-reimbursed personal care services, in July. EVV is now pushed back until Jan. 1, 2020 at the earliest.

The bill passed through both the U.S. House of Representatives and Senate without opposition.

CMS floated the concept of an EVV implementation tracking survey on Friday.

“This collection entails an electronic web-based survey that will allow states to self-report their progress in implementing [EVV] for personal care services and home health care services,” the agency wrote in a Federal Register post. “CMS will use the survey data to assess states’ compliance … and levy Federal Medical Assistance Percentage (FMAP) reductions where necessary.”

Data collection would begin in November 2019 and end when all states have fully implemented EVV systems, according to CMS.

The survey would be disseminated to all 51 state Medicaid agencies — including in Washington, D.C. — and the Medicaid agencies of five U.S. territories. States would be required to complete the survey in order to demonstrate EVV compliance.

The survey would be live form, meaning states would have the ability to update their compliance on an ongoing basis.

Nearly three dozen states have already finished or taken significant steps toward putting verification systems in place, according to the Partnership for Medicaid Home-Based Care.

Written by Robert Holly

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