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  • CMS Will Shift Home Health Agencies to a 'Pre-Claim Review' Model in 5 States

    In a step that it hopes will help educate home health agencies (HHAs) and prevent improper payment, the Centers for Medicare and Medicaid Services (CMS) will soon require HHAs in 5 states to participate in a pre-claim review process for their Medicare patients.

    Beginning with Illinois on August 1, 2016, CMS will require HHAs to submit supporting documentation for services while beneficiaries are receiving care. CMS will review the pre-claim and make a review decision "generally within 10 days," according to a CMS fact sheet. The other 4 states—Florida, Texas, Michigan, and Massachusetts—will be phased into the program during the rest of the year and into 2017.

    According to CMS, the documentation will be "the same type of documentation [HHAs] currently gather for payment, only HHAs will submit it earlier in the process." The new program does not change eligibility standards, and CMS states that it will allow HHAs to submit additional pre-claim documentation to support the claim should CMS find the initial submission lacking. HHAs can receive initial payments before CMS makes its pre-claim review decision, and if a claim is not approved during the pre-claim process, the HHA can appeal.

    Once the program has been operational for 3 months in a demonstration state, HHAs that submit a claim without a pre-claim review may still receive payment, but at a 25% reduction of the full claim amount—if they they are approved at all. These claims will go through the same pre-claim review process and may be subject to denial.

    The new program is an attempt to tighten up an HHA claims process that reached a 59% improper payment rate in 2015, with a large proportion of those improper claims linked to insufficient documentation. "The pre-claim review demonstration will help educate HHAs on what documentation is required and encourage them to submit the correct documentation," CMS states.

    The project is also designed to shift CMS away from a "pay and chase" approach that forces the agency to demand repayment of money already spent and toward a more preventive model. According to CMS, "most" of the 5 states targeted for the demonstration project have been identified as at "high risk" for improper payment.

    APTA will monitor implementation of the program to evaluate its effects on access to physical therapy, and will work with other stakeholders to ensure that CMS does not unfairly penalize all HHAs and the physical therapists who practice in home health settings.


    • Could they possibly give us any more hurdles!! Penalizes agencies that are doing it right and adds to the cost of doing business.

      Posted by Jeff senn on 6/22/2016 10:03 PM

    • Not everyone in the HH business provides good care and the tendency is to keep the patients in treatment too long and only see them for 30 minutes or less. The patient reaches a point in which going to OP would be more beneficial and improve their outcome and recovery faster.. We have done this to ourselves over many years!!

      Posted by Vanie Jones on 6/25/2016 12:58 PM

    • CMS stated that the documentation will be "the same type of documentation [HHAs] currently gather for payment, only HHAs will submit it earlier in the process." You want to bet? My company will probably add more documentation in preparation for this. Unreal...

      Posted by Jennifer HomeHealth PT on 6/26/2016 3:56 PM

    • Shouldn't the doctors have the say in physical therapy and home health care and not insurance companies?

      Posted by Without a nurse for mom on 9/30/2016 2:07 AM

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