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CMS Pre-Claim Review Initiative Delayed, Not Dead

Readers of the Allegiant Experts Blog can be pretty sure about one thing: health insurance fraud is rampant throughout the United States. And while our team of clinical experts continues to work with attorneys who are battling cases of both fraud and medical misconduct, we also continue to be inundated with stories about how Medicare and Medicaid are constantly being ripped off. Well, thankfully, extra measures are now being taken to prevent that.

On August 3rd of this year, the Centers for Medicare & Medicaid Services (CMS) launched a pre-payment claims review policy with the intention of significantly reducing the amount of errors being made with healthcare claims. Known as the CMS Pre-Claim Review Demonstration for Home Health Services, the pilot rolled out in the State of Illinois with the intention of being launched in Florida this month and eventually throughout the United States.

Unfortunately, a number of issues surrounding provider education have arisen over the past couple of months. Apparently, there is a lot still to be learned by providers about how to properly submit the pre-claim submissions. As a result, CMS has postponed the rollout of the policy in other states until the providers in those states have been properly educated.

CMS issued the following statement on their website: “Based on early information from Illinois, CMS believes additional education efforts will be helpful before expansion of the demonstration to other states; therefore, we will not move forward with initiating the demonstration in Florida in October. This education effort will focus on how to submit pre-claim review requests, documentation requirements, and common reasons for non-affirmation.”

They go on to assert that the efforts being made to educate providers are “crucial to the long-term success of the demonstration for beneficiaries, providers, and the Medicare program.” There is no word yet on when the policy will be rolled out in such states as Florida, Texas, Michigan and Massachusetts, but CMS has assured that it will provide at least 30 days’ notice on their website prior to beginning in any state.

There are providers, however, that are completely opposed to the rolling out of the CMS Pre-Claim Review Demonstration for Home Health Services. As Tim Mullaney of Home Health Care News reports, there are home health providers and advocacy groups that are calling for the policy to be completely suspended. They appear to be of the opinion that the program will force numerous agencies out of business.

Mullaney notes that many providers expressed their disinterest in the policy at a summit on pre-claim that was held in Chicago late last month. It was organized by home health software provider, Homecare Homebase. “I was sweating bullets until the moment (I learned of the delay),” one of these providers who preferred to remain anonymous was quoted as saying. “How can you decide to delay in Florida because it’s not working, but still keep Illinois involved?” asked another.

The team, here at Allegiant Experts disagrees that the CMS Pre-Claim Review Demonstration for Home Health Services is “not working”. We are of the mind that the initiative is, indeed, very valuable as it will work to ensure that healthcare claims submitted for home healthcare services are legitimate and reasonable. It will also seek to provide correct and fair payments to providers while ensuring the responsible use of Medicare Trust Fund Monies.

For more information about how the team of clinical experts at Allegiant Experts can help you to fight healthcare fraud, please don’t hesitate to contact us at 407-217-5831

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