A new demonstration project will require pre-claim review for home health agencies (HHAs) prior to payment in five states. In an advance release, CMS stated that this demonstration will serve as an anti-fraud tool to prevent improper payments and protect program integrity. CMS assures beneficiaries that they will continue to receive immediate care once services are ordered, but agencies will be required to submit supporting documentation during the provision of care.
The demonstration will not impose new documentation requirements on HHAs, and does not change the home health service benefit for beneficiaries. HHAs in the participating states (Illinois, Florida, Texas, Michigan, and Massachusetts) will be required to submit all supporting documentation while providing care. Beneficiaries are also permitted to submit documentation for pre-claim review. CMS has established a timeframe of about 10 days for a decision, giving the HHA or the beneficiary an option to submit additional documentation if the agency finds that the original submission is inadequate.
Errors and fraud
HHAs are prone to errors in documentation and present a risk of fraud, abuse, and waste to federal health care programs. The improper payment rate for HHAs was 59 percent in 2015, which can be largely attributed to insufficient documentation. Research indicates that the majority of home health payment errors occur when the narrative portion of the documentation did not sufficiently show that the patient was homebound and in need of home health services. CMS plans to use the demonstration to educate HHAs on what is required, and will allow HHAs to submit documentation as many times as necessary during review.
HHAs are so prone to fraud and abuse that CMS has issued a moratoria preventing new enrollment of home health providers in markets indicating high risk, including Miami, Chicago, Dallas, and Houston (see Home health fraud bigger in Texas; convictions in $376M scheme, Health Law Daily, April 14, 2016; Fighting home health and ambulance fraud by putting providers on a map, Health Law Daily, February 23, 2016). CMS believes that the pre-claim review process will be another tool available to prevent fraud, rather than attempting to reclaim fraudulent payments.