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CMS Holds Open-Door Forum on its Upcoming HHA Pre-Claim Review Demonstration

On June 14, 2016 between 2 and 3pm EST, CMS had a special open-door forum (ODF) regarding its pre-claim review demonstration for home health services (the “Demonstration”) which will take place in Illinois, Florida, Texas, Michigan and Massachusetts (listed chronologically by implementation date; see our prior blog post on the Demonstration for more information regarding the details of CMS’ pre-claim review process). During the ODF, home health agencies (HHAs) had the opportunity to learn more about the Demonstration and to ask CMS questions regarding pre-claim reviews.  In addition to the questions, some HHAs took the opportunity to raise concerns they had regarding the Demonstration.

CMS started by addressing the basics of the program, specifically that HHAs will be required to submit a pre-claim review request prior to submitting the final bill for payment.  CMS then restated that the Demonstration’s goal is to assure that HHA services are medically necessary and reasonable; to determine this, the Medicare Administrative Contractors (MACs) reviewing the pre-claim review requests will evaluate the submitted documentation to assure that the beneficiary: 1) is confined to home at time of service; 2) is under a physician’s care; 3) receives care pursuant to a plan of care approved by the physician; 4) is in need of skilled services; and 5) has had a face-to-face encounter with his or her certifying physician and the physician’s observations support the certification for home health services.

The statements from the ODF’s participants varied from logistical questions to expressions of concern over the impending Demonstration. On the logistical side, after CMS stated that a unique tracking number (UTN) would be provided once a pre-claim review was approved, participants requested guidance on where to place the UTN on the final bill. CMS explained that an operational guide for the Demonstration would be released within “the next few weeks.” The guide is to include information on what fields to put certain information (including UTNs) into, along with other procedural and administrative guidance for the Demonstration’s roll-out. CMS also answered a question on whether there would be specific forms provided for HHAs to fill out when filing the pre-claim review request: CMS stated that while no document was available yet, one would be made available in the future, and that the forms themselves would generally be furnished by the individual  MACs in each region, rather than CMS itself.

Ultimately, CMS spent most of the ODF on defense, reiterating its commitment to the impending Demonstration. During its question period prior to passing the official plan, CMS had received a high amount of negative feedback, and this only continued during the ODF. One participant asked if additional money would be given to HHAs for home health services reimbursement to cover the additional cost of hiring staff to prepare the pre-claim review requests. CMS responded in the negative, making it clear that no additional resources would be allotted. However, CMS asserted that the documentation requirements would not increase under the Demonstration, and that the most major change would be that the documentation would need to be filed earlier on in the process and that that HHAs will now know at the time of filing the final claim whether or not it will be reimbursed. CMS also pointed out that HHAs would still have access to the traditional Medicare appeals process.

Numerous questions also went on to challenge the validity of CMS’ assertion that pre-claim reviews would be processed within 10 days of being received. According to CMS, the MACs would increase their workforce to deal with the additional influx of requests, with many new employees having already been hired. CMS ultimately conceded that there would be an adjustment period for both the MACs and the HHAs themselves, but did not seem concerned that any backlog of pre-claim requests would form, nor that there would be any excessive delays. One caller even voiced apprehension over delays due to review requests being lost in the mail, to which CMS replied that electronic submissions would be accepted, and that requests submitted electronically would be responded to in kind.

Participants in the ODF also articulated unease regarding the new MAC employees’ ability to adequately and appropriately review the pre-claim requests, stemming from HHAs’ experience during the Medicare appeals process, where reviewers often apply incorrect standards when appraising HHA claims for medical necessity and/or documentation requirements.  Yet another participant opined that the Demonstration sounded like a 100% probe audit.  In response, CMS repeated its sentiment that the Demonstration places no additional documentational burden on the HHAs and that the HHAs will now simply know whether or not their claim will be paid by the time the final bill is submitted.

Because of the potential for claim rejections and reimbursement penalties, it is important for HHAs to understand the requirements so as to be compliant by the time the program becomes effective (as early as August 1, 2016 in Illinois).

Wachler & Associates represents healthcare providers and suppliers nationwide in a variety of health law matters, including compliance with Medicare regulations and appeals of claim denials. If you or your home health agency have any questions regarding compliance with the new pre-claim review demonstration or other healthcare laws pertaining to Medicare or Medicaid, or healthcare regulatory compliance in general, please contact an experienced healthcare attorney at (248) 544-0888, or via email at You may also subscribe to our health law blog by adding your email at the top right of this page.

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