CMS to take closer look at payments to Illinois home health agencies

Illinois home health agency claims will again be under scrutiny as the Centers for Medicare and Medicaid Services gets set to launch a revamped version of a program it halted last year aimed at rooting out fraud.

CMS is requiring that home health agencies make a certain amount of claims available for review before or after submission.

Illinois was the only state that participated in the Pre-Claim Review Demonstration before CMS paused it in 2017. Starting in December, Illinois will be the first state required to take part in the Review Choice Demonstration. CMS also plans to roll the program out in at least four other states: Ohio, North Carolina, Florida and Texas.

CMS is initially focusing on these states because they are seen as having “extensive fraud within the Medicare home health benefit for participation,” according to a spokesperson. Illinois was picked to go first because it had a smaller number of claims than the other target states.

Providers can choose if they want CMS to review their claims before or after they submit them. They can also opt for a post-payment review of a smaller number of claims, but that comes with a 25 percent reduction in reimbursement.

Illinois agencies that performed well in the first round of the program – those that achieved a 90 percent affirmation rate – have two additional options. They can choose a post-payment review of a random sample of claims or a pre-payment spot check review.

“We lobbied hard for agencies to get some sort of credit for positive past performance,” Sara Ratcliffe, executive director of the Illinois HomeCare and Hospice Council, told Health News Illinois.

Ratcliffe is pleased that CMS is providing high-performing agencies with more choices, but she said the program will still take significant resources to implement. She also expressed concern that CMS was not sharing enough information with agencies, including how the Pre-Claim Review Demonstration impacted care.

“We want to know how we performed,” she said. “I think that’s only fair for them to be transparent about that.”

A CMS spokesperson said they shared regular public updates during the initial demonstration and plan to continue sharing data in the revised demonstration.