On Tuesday, May 29, 2018, the Centers for Medicare and Medicaid Services (CMS) released a new proposal that would reinstate pre-claim review for home health care providers. Like previous medical review strategies, the proposed Review Choice Demonstration for Home Health Services will focus on reducing the rate of improper payments and improving provider compliance. Unlike previous medical review strategies, this proposed demonstration will give home health providers the choice of three options:
1. 100 Percent Pre-Claim Review
With this option, the Home Health Agency will send the pre-claim review request along with all required documentation to the Medicare contractor for review prior to submitting the final claim for payment. If a claim is submitted without a pre-claim review decision on file, the provider will receive an Additional Documentation Request (ADR) from the Medicare contractor requesting the information to determine if payment is appropriate.
2. 100 Percent Post-Payment Review
With this option, the provider will receive an ADR from the Medicare contractor, following payment of the final claim, requesting the information to determine if payment is appropriate.
3. No Claim Submission for Review
Providers can opt to submit claims for payment without review and receive a 25 percent payment reduction for all home health services. CMS warns that choosing this option can potentially lead to review by Recovery Audit Contractors (RAC).
Once an 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.
The proposed Review Demonstration will begin with Jurisdiction M (Palmetto) which includes Illinois, Ohio, North Carolina, Florida and Texas. The initial demonstration is for five years with the option to expand to other states in the jurisdiction.
Per CMS, the Review Choice Demonstration for Home Health Services will not create new clinical documentation requirements since providers will submit the same information that is currently required for payment.
CMS has posted a 60-day notice in the Federal Register, giving providers until July 30, 2018 to review and comment on this proposal.