CMS Announces New Version of Pre-Claim Review

Posted on Thursday, May 31, 2018 6:32 PM

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

In the new plan, home health agencies (HHA) can choose either pre-claim or post-payment reviews, or they can choose not to be reviewed in exchange for a 25% decrease on all claim payments.  “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 plans to roll out the reviews in the following states: Illinois, Ohio, North Carolina, Florida and Texas.  If successful CMS will expand to other states under the Palmetto/JM Medicare Administrative Contractor (MAC).

This would be CMS’ second attempt at a pre-claim review program for home health. The first rolled out in Illinois in 2016 but was paused indefinitely just before it was set to take effect in its second state, Florida.

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