CMS Proposes to Implement Revised Home Health Pre-Claim Review Demonstration

Kevin R. Miserez, Esq.

On May 29, the Centers for Medicare & Medicaid Services (CMS) published its 60-day notice to allow interested stakeholders the opportunity to comment on CMS’s proposed Review Choice Demonstration for Home Health Services (“revised demonstration”). The Review Choice Demonstration is a revised version of the CMS’s previous Pre-Claim Review Demonstration for Home Health Services, which was paused by CMS on April 1, 2017. According to CMS, the revised demonstration will “offer more flexibility and choice for providers.”

Under the revised demonstration, home health agency (HHA) providers subject to the demonstration have the choice of participating in either a 100% pre-claim review or 100% post-payment review. These HHAs will remain under the chosen review method until the HHA reaches the target affirmation (for pre-claim reviews) or claim approval rate (for post-payment reviews). At this time, CMS has not provided any specific benchmarks with respect to the requisite “target affirmation” or “claim approval rate” HHAs will need to satisfy. However, once the target affirmation or claim approval rate has been met, HHAs may choose to be relieved from claim reviews with the exception of a “spot check” of their claims to ensure continued compliance.

Under the pre-claim-review option, CMS will review the medical documentation prior to payment to determine if the home health services meet all of the coverage requirements. The review request may be submitted at any time before the final claim is submitted and can occur after home health services have begun. According to CMS, the pre-claim review does not create new documentation requirements; rather, HHAs will submit the same information they are currently required to maintain for payment. Under the post-payment review option, the review by CMS will occur after the beneficiary has received the home health services and the HHA has received an Additional Documentation Request (ADR) for the particular claims under review.

In addition to the forgoing pre-claim and post-payment review options, CMS has also proposed a third option for those HHAs that do not wish to participate in either 100% claim review. Under this third option, HHAs may continue to furnish home health services and submit the associated claim for payment without such claims being reviewed, but those HHAs opting to do so will receive a 25% reduction in payment on all claims submitted. Moreover, CMS indicated in its notice that HHAs under the third option may still be eligible for review by Recovery Audit Contractors.

The precise start date for the revised demonstration has not currently been announced but will begin no earlier than October 1, 2018 and will last for five years. Furthermore, the revised demonstration will initially only be in effect for HHAs located in five (5) states, which will be implemented on a staggered basis beginning with the state of Illinois, followed by expanding to Ohio, North Carolina, Texas, and Florida, respectively. According to CMS, “These states include known areas of fraudulent behavior and had either a high home health improper payment rate or a high denial rate during the Home Health Probe and Educate reviews.”

While the revised demonstration is currently only proposed to be implemented in the five states above, CMS indicated in its public notice that it has the option to expand to other states if there is increased evidence of fraud, waste or abuse in these states during the demonstration period. Accordingly, it is unknown at this time whether any additional states and/or which additional states could eventually become subject to the revised demonstration program or similar type of claim review process down the road. For example, states that could be potential targets to such types of reviews in the future may be those with areas currently subject to CMS’s temporary HHA enrollment moratoria as these states, including Michigan, have previously been determined by CMS as having significant potential for fraud, waste, or abuse with respect to HHA services. Therefore, HHAs outside of the fives states currently being targeted should nevertheless ensure their claims and supporting medical documentation meet all of the Medicare coverage requirements for home health services.

CMS is seeking comments from the public regarding this proposed revised demonstration. Any home health stakeholders should ensure their comments are submitted by the July 30, 2018 deadline.