In 2016, CMS rolled out a pre-claim review demonstration which was stopped by stakeholders with the aid of Congress. The initiative was to require that claims be sent in earlier in the claims process. CMS has revived the initiative with some modifications. Policy experts believe that stakeholders will not be able to stop the new version of the pre-claim review. The April 2018 report of the Government Accountability Office was probably the death knell for the efforts of opponents. The new version is called “review choice demonstration.” If implemented, it will go into effect in Illinois, which was the original venue of choice in 2016, on December 10, 2018. Here are some aspects of the new version:
CMS’ new version of pre-claim review — now called the review choice demonstration — allows home health agencies to forgo prior claims authorization in favor of post-payment review. In post-payment review, providers would affirm claims after they had already received payment, giving CMS the opportunity to rescind funds if any issues are uncovered.
The proposal additionally allows home health providers to opt out of prior and post-payment review and instead take a 25% reduction on all payments for claims submitted. Providers that achieve a targeted claim approval rate can choose to opt out of claim reviews in favor of a spot check to ensure continued compliance.
