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CMS proposes to resume pre-claim demo, potentially expand it to more states

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CMS is seeking public input into relaunching a pre-claim review demonstration for home health services. States that are potentially affected are located within the Medicare Administrative Contractor (MAC) Palmetto GBA’s jurisdiction.

“CMS proposes initially implementing the demonstration in Illinois, Ohio, North Carolina, Florida and Texas with the option to expand to other states in the Palmetto/JM jurisdiction,” CMS says in a comment request posted on the Federal Register website May 29.

CMS is proposing to offer agencies choices in how to demonstrate compliance — either 100% pre-claim reviews or 100% post-payment reviews.

Once an agency reaches a target affirmation or claim approval rate, “it may choose to be relieved from claim reviews, except for a spot check of their claims to ensure continued compliance.”

Agencies that decide not to participate in pre-claim or post-payment reviews may provide services and submit the claim. But they’ll receive a 25% payment reduction on all claims submitted and may be eligible for review by the recovery auditor (RAC).

The goal of such reviews is to “help assist in developing improved procedures for the identification, investigation and prosecution of Medicare fraud” among agencies providing care to Medicare beneficiaries, CMS says.

Originally, the pre-claim demo had been expected to occur in five states: Illinois, Florida, Michigan, Massachusetts and Texas. But it never occurred outside of Illinois.

The pre-claim review demonstration originally began in Illinois in August 2016 and was paused March 31, 2017 — one day before it was set to expand to Florida.

Many Illinois agencies had major challenges with the demonstration before it was paused. Although about 90% of pre-claim review requests submitted in week 24 of the demo in Illinois received a fully affirmed decision, only about 30% of the requests in weeks three and four were fully affirmed, CMS data show.

Agencies will have 60 days to comment on CMS’ request from when it’s published officially in the Federal Register in the coming days. Agencies may submit comments to

Read more about CMS’ comment request at