CMS Announces New Pre Claim Model for Home Health Agencies

Three-Year Model to Affect Five States

CMS announced Wednesday they are implementing a three year Pre-Claim model for Home Health. The model had started out as a pre-authorization and morphed into the pre-claim review. Many in the industry had hoped recent collaboration from industry groups, leaders, and members of congress would be enough to convince CMS against moving forward.

The model tests 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. CMS said the pre-claim review demonstration will not create new clinical documentation requirements and that HHAs will submit the same information they currently submit for payment, just earlier in the process. Medicare will review the documentation to determine if all coverage requirements for home health services are met and will issue a pre-claim review decision within ten days. If the documentation submitted was not sufficient, then the HHA (or beneficiary) may submit additional documentation to support the claim. Once sufficient documentation is submitted, Medicare will make timely payment on the home health services claim following the standard process. If a claim is ultimately not approved during the pre-claim process, then the final claim for payment would be denied, but the HHA may appeal that determination.

If the HHA fails to submit a request for pre-claim review, but the final claim is submitted for payment, then the final claim will be subject to a pre-payment medical review. After the first three months of the demonstration in each participating state, if claims are submitted without a pre-claim review and are determined to be payable, they will be paid at a 25% reduction of the full claim amount. This will not be subject to appeal or be able to be recouped from or otherwise charged to the beneficiary.

I reached out industry expert Mary St. Pierre, RN, BSN, former VP of Regulatory Affairs with the National Association of Home Care and Hospice and HEALTHCAREfirst consultant, for her thoughts on the rule and she stated that it reminded her of the days when HHAs were required to submit their 485 and 486 with claims. Unfortunately the MACs were so overwhelmed, that they couldn’t keep up with tracking, filing, and reviewing them and the initiative only lasted about one year. Mary also had concerns this would not only impact the paperwork process, but the willingness of HHAs to initiate care before receiving an approval.

CMS has not set an exact date for when the demonstration will begin, however they said it will begin no earlier than the following dates for the impacted states:

  1. No earlier than August 1, 2016 in Illinois.
  2. No earlier than October 1, 2016 in Florida.
  3. No earlier than December 1, 2016 in Texas.
  4. No earlier than January 1, 2017 in Michigan and Massachusetts.

Exact start dates for Florida, Texas, Michigan, and Massachusetts will be determined and announced in the coming months.

Most of the specific details involved with the roll-out of this change are not yet known, however CMS will host a Special Open Door Forum next Tuesday, June 14 from 2 – 3 pm ET:

Special Open Door Forum Participation Instructions:
Participant Dial-In Number: 1-800-837-1935
Conference ID #: 94873140

HEALTHCAREfirst will participate in the Special Open Door Forum and recommends that all HHAs in the impacted states also participate. The full ruling can be accessed here: CMS has also released the following information on the Pre-Claim Review Demo that has FAQs attached:

Questions regarding the Medicare Pre-Claim Review Demonstration for Home Health Services can be sent to

As additional details are made available, HEALTHCAREfirst will post them to the blog.

Tell us in the comments below, what are your thoughts about this Pre-Claim Model?