June 8, 2016

Medicare to Scrutinize Home Health Claims in Five States

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Bloomberg BNA

Development: CMS says it’ll conduct a pre-claims reviews of home health services for three years in Illinois, Florida, Texas, Michigan, Massachusetts.

Timing: Illinois is first state for reviews, starting later this summer.

June 8 (BNA) — The Medicare program is moving ahead in five states with pre-claims reviews to deter home health services fraud, according to a notice released June 8.

The Centers for Medicare & Medicaid Services announced a three-year Medicare pre-claim review demonstration for home health services in Illinois, Florida, Texas, Michigan and Massachusetts.

The agency said the pre-claim review process for home health agencies (HHAs) will help identify, investigate and prosecute fraud among HHAs that serve Medicare beneficiaries.

The agency said the demonstration will begin in Illinois no earlier than Aug. 1, in Florida no earlier than Oct. 1 and in Texas no earlier than Dec. 1. For Michigan and Massachusetts, the demonstration will begin no earlier than Jan. 1, 2017, the agency said.

Providers in each state will be notified by the appropriate Medicare administrative contractor prior to the start of the demonstration in the state, the CMS said.

The agency said this demonstration will bolster the CMS’s efforts in implementing “a series of anti-fraud initiatives in these states and will provide valuable data that CMS, working with its law enforcement partners, can use to combat the submission of fraudulent claims to the Medicare program.”

The agency noted that the government has temporarily halted the enrollment of new home health providers in the Miami, Chicago, Fort Lauderdale, Detroit, Dallas and Houston metropolitan areas in an effort to cut fraud among HHAs.

The Medicare home health benefit allows beneficiaries who are deemed homebound to receive certain medically necessary services in their homes, “which is a preferred setting for many beneficiaries,” the agency said in a fact sheet.

However, the CMS noted that in 2015 home health claims had a 59 percent improper payment rate, “and a large proportion of the improper payment rate was because of insufficient documentation.”

The agency said its review demonstration will help educate providers on what documentation is required and encourage them to submit the correct documentation, while still allowing the home health agency to begin providing services and receive initial payments prior to the pre-claim review decision.


Lawmakers have expressed displeasure with the agency’s plans for this demo. In late May, a group of lawmakers asked the CMS and Health and Human Services Secretary Sylvia Mathews Burwell to hold off on the demonstration involving prior authorization.

“We are concerned that a demonstration project centered on prior approval or ‘prior authorization’ of home healthcare would interfere with the patient-doctor relationship and is in conflict with the policy goal of moving toward patient-centered care,” the letter from the bipartisan group of House members said (See previous story, 05/27/16).

The letter referred to a Feb. 5 Federal Register notice under the Paperwork Reduction Act (81 Fed. Reg. 6,275). At that time, the agency said it was considering collecting additional medical records for home health through a prior authorization process. Comments on that notice were due in April.

Colin Roskey, executive vice president at the Partnership for Quality Home Healthcare and a partner at Alston & Bird, told Bloomberg BNA the demonstration “should have gone through the notice and comment period but didn’t.” He said 280 comments were received by the CMS on the earlier notice about the demonstration, but these concerns aren’t reflected in the latest notice issued by the agency.

Home health providers already are subject to a plethora of paperwork requirements, Roskey said. “Providers of services face an unrealistic and at times confusing and duplicative array of requirements associated with determining Medicare program eligibility,” he said.

The latest Federal Register notice is slated for publication June 10.

Click here to see the original article on the Bloomberg BNA website.