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Review Choice Demonstration for Home Health Services

Following the pause of the Pre-Claim Review Demonstration for Home Health Services on April 1, 2017, the Centers for Medicare & Medicaid Services (CMS) worked to revise the Demonstration to offer more flexibility and choice for providers, as well as risk-based changes to reward providers who show compliance with Medicare home health policies.  The proposed Review Choice Demonstration for Home Health Services will give providers in the demonstration states an initial choice of three options – pre-claim review, postpayment review, or minimal postpayment review with a 25% payment reduction for all home health services. A provider’s compliance with Medicare billing, coding, and coverage requirements determines the provider’s next steps under the Demonstration. CMS will implement the Demonstration for the Home Health and Hospice Medicare Administrative Contractor Jurisdiction M (Palmetto) providers operating in Illinois, Ohio, North Carolina, Florida, and Texas for five years, with the option to expand to other states in the Palmetto/JM Jurisdiction. 

The revised Demonstration will assist in developing improved methods to identify, investigate, and prosecute potential fraud in order to protect the Medicare Trust Funds, potentially reduce the rate of improper payments, and improve provider compliance with Medicare rules and requirements. Through either pre-claim or postpayment review, the Demonstration will help make sure that payments for home health services are appropriate.

The Review Choice Demonstration for Home Health Services should not delay care to Medicare beneficiaries and does not alter the Medicare home health benefit. The Demonstration will not create new clinical documentation requirements. Providers will submit the same information they are currently required to maintain for payment.  Under the pre-claim review option, the pre-claim review request may be submitted at any time before the final claim is submitted and can occur after home health services have begun.  Under the other review options, the provider will receive an Additional Documentation Request (ADR) and follow the normal processes for claims chosen for review.

CMS has posted a 60-day Federal Register Notice here to allow providers the opportunity to review and comment on CMS’ intention to collect information from the public for the revised demonstration as part of the Paperwork Reduction Act (PRA) approval process. Additional details on the Demonstration and start dates will be published following PRA approval.