Home Health Preclaim Review Demonstration Announced for Five States

June 17, 2016 | Aging Services Risk, Quality, & Safety Guidance

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​Home health agencies in five states will begin participating in a preclaim review demonstration that the Centers for Medicare and Medicaid Services (CMS) says is intended to help reduce fraud and abuse by ensuring that relevant coverage and clinical documentation are present before claims are paid. Home health agencies in the demonstration states that do not submit the necessary information prior to submitting a claim will have their payment reduced by 25%, even when the claim is deemed payable. In frequently asked questions accompanying the announcement, CMS specifies that preclaim review is different from preauthorization review, in that preclaim reviews take place after the provision of services has begun, where preauthorization review takes place before any services are provided. CMS also states that the preclaim review will not create new documentation requirements, although it does not specify the information that it will require agencies to submit for review; reviews will be conducted by Medicare administrative contractors.

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