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

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.

Full story of home shift agencies and ‘Pre-Claim Review’ model at APTA 

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