Find-A-Code Focus Newsletter

Pre Claim Review being done by Medicare

June 13, 2016

Medicare is implementing a three year Pre-Claim Review Demonstration of Home Health Services in the states of Illinois, Florida, and Texas beginning in 2016, and in the states of Michigan and Massachusetts beginning in 2017.  CMS is testing whether pre-claim review improves methods for the identification, investigation, and prosecution of Medicare fraud occurring among Home Health Agencies (HHAs) providing services to people with Medicare benefits.  Additionally, CMS is also testing whether the demonstration helps reduce expenditures while maintaining or improving quality of care.  

The review is to verify the documentation covers all of the coverage requirements for home health services.

The main change under this demonstration is that HHAs will submit the supporting documentation while beneficiaries are receiving care, Medicare will issue a pre-claim review decision generally within 10 days.   This earlier submission of documentation will undergo the new “pre-claim review.”  

CMS will help make sure that home health services are medically necessary without delaying or disrupting patient care or access.  The pre-claim review demonstration will begin in Illinois no earlier than August 1, 2016, and the remaining states will phase in during 2016 and 2017.

 A beneficiary may also submit documentation for pre-claim review.  To read the entire article click here


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