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The Pre Authorization Demonstration is now revised to a Pre-Claim Review Demonstration for Home Health Services

On Tues., June 14th, the Centers for Medicare and Medicaid Services (CMS) will host a Special Open Door Forum (SODF). The SODF will provide an opportunity for home health agencies, physicians, and other interested parties to learn about the new Pre-Claim Review Demonstration for Home Health Services.

CMS will be implementing a 3-year Medicare pre-claim review demonstration for home health services in the states of Illinois, Florida, and Texas by the end of 2016. CMS plans to include Michigan and Massachusetts in the demonstration in 2017. CMS is testing whether pre-claim review helps reduce expenditures, while maintaining or improving quality of care.  CMS believes the demonstration will also help assure services are provided in compliance with applicable Medicare coverage and payment rules, thereby assisting in the prevention of fraud, waste, and abuse. 

LeadingAge NY joined with LeadingAge and others to voice our concerns with the prior authorization demonstration. Concerns with the prior authorization demonstration may be similar to the pre-claim demonstration. Some of the concerns included:  the possibility of providing a barrier to services, creating another layer of an administrative burden to providers, and possibly delay care to seniors at a time when the delay could have negative patient outcomes. A prior authorization demonstration was previously done for Power Mobility Devices (PMD) in 2012, as a means to defer fraud. As it was stated in our letter to CMS, “We believe prior authorization decreases utilization, without effectively targeting inappropriate utilization due to fraud.” We are also concerned that CMS is viewing PMDs in same light as providing services. There needs to be another avenue for deferring fraud and abuse. LeadingAge has posted another article on this latest development.

To learn more about the Pre-Claim Review Demonstration for Home Health Services, click here.  CMS has published a Fact Sheet to help explain the demonstration. Please see below CMS's distinction between a “pre-claim review and a prior-authorization” from the Frequently Asked Questions (FAQs) document

According to the FAQs, “A pre-claim review is different than a prior authorization due to the timing of the review and when services may begin. For prior authorization, a request must be submitted prior to services beginning and providers should wait until they have a decision before they begin providing services. With a pre-claim review, services have already begun and the request is submitted after all of the initial assessments and intake procedures are completed and services have begun. The pre-claim review occurs after services start but prior to the final claim being submitted.”

The call will be held today Tues., June 14th, from 2-3 p.m. 

Participant dial-in number 1-800-837-1935: reference conference code ID: 94873140.

Contact: Cheryl Udell, cudell@leadingageny.org, 518-867-8871