Home Health Pre-Claim Review Reappears


Home Health Pre-Claim Review Reappears

A pending notice on the Federal Register’s Centers for Medicare and Medicaid Services (CMS) website quietly appeared this week announcing the launch of the reemergence of Pre-Claim Review (PCR) for home health agencies in certain states. The document, which outlines plans for PCR in Illinois, Ohio, North Carolina, Florida, and Texas, was scheduled for publication yesterday. The document also states that CMS has the option to expand into additional states in the Palmetto/JM jurisdiction.

Pre-Claim Review first surfaced in 2016 as a three-year demonstration model to identify, investigate, and prosecute fraud in the home health space. At that time, agencies in Illinois, Florida and Texas were slated to begin PCR in 2016, with Michigan and Massachusetts to join in 2017. However, a less-than-stellar roll-out in August 2016 in Illinois caused CMS to suspend the model on April 1, 2017 “for at least 30 days”. The demonstration model remained quiet until this week, when the public notice was issued to publish a 60-day notice in the Federal Register.

In the CMS announcement, an updated model is laid out with additional choices for the participating agencies. These options are one of the following: 1) 100 percent pre-claim review, 2) 100 percent post-payment review, or 3) No review with an across-the-board 25 percent payment reduction on all final claims. Once the agency submits either pre- or post-claim reviews and has reached the target affirmation rate, it may choose to be relieved from ongoing audits, except for occasional spot checks for compliance. On the other hand, those who choose the option for no review and a 25 percent cut in payment are eligible for Recovery Audit Contractor review.

These review actions are part of an ongoing plan to eliminate fraudulent billing practices and to ensure that agencies fully understand and are compliant with the criteria for billing home health services under Medicare and Medicaid. The criteria for Medicare home health services are found in CMS publication 100-2, Chapter 7, the Medicare Benefit Policy Manual for Home Health. Medicare billing guidance is found in CMS publication 100-4, Chapter 10, Home Health Agency Billing Manual. These manuals include the criteria for Certification, Face to Face requirements, Homebound Status criteria, Medical Necessity, Skilled services guidelines, and billing requirements.

Agencies would be well advised to review these manuals and ensure their processes are in order before the rollout of pre- and post-payment review models in the near future.

CMS will solicit comments regarding the plan to reinstate pre-claim review, and agencies are encouraged to send comments prior to the end of July.

For more information, please see the preliminary CMS announcement.

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