CMS is considering implementing a Medicare home health claims review demonstration project intended to help identify, prevent, and prosecute Medicare fraud, waste, and abuse and reduce Medicare appeals. Under this initiative, CMS would offer home health agencies (HHAs) in the demonstration area the choice of demonstrating their compliance with Medicare home health policies through 100% pre-claim review or 100% postpayment review. The claims review would continue until the HHA reaches a “target affirmation or claim approval rate,” at which point the HHA may choose to be relieved from claim reviews except for a “spot check” to ensure continued compliance. An HHA may choose not to participate in either the pre-claim or postpayment reviews, but the provider will receive a 25% payment reduction on all home health claims and may be subject to Recovery Audit Contractor review. CMS proposes to implement the demonstration initially in Illinois, Ohio, North Carolina, Florida, and Texas, with the option to expand to other states in the Palmetto/JM Medicare Administrative Contractor (MAC) jurisdiction. CMS will accept comments on the demonstration until July 30, 2018.
Home Regulatory Developments Centers for Medicare & Medicaid Services Regulations CMS Considering Home Health Claims Review Demonstration