A Guide To The Pre-Claim Review Process

BACKGROUND

In 2012, The Office of Inspector General (OIG) found that 98% of medical records document Medicare coverage requirements for home health services. However, home health agencies (HHAs) submitted 22% inaccurate claims because services were unnecessary or claims were inaccurately coded, resulting in $432 million in improper payments. While the Centers for Medicare and Medicaid Services (CMS) has implemented numerous tactics to reduce fraud (whether intended or unintended), suggestions have been made that additional monitoring, edits, and restrictions should be placed on HHAs for further reduction.
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