Pressure Builds to Dump Medicare Pre-Claims Review Demo


The Medicare pre-claims review program is designed to avoid unnecessary or improper payments, but for a bipartisan group of Florida lawmakers, a home-health pre-claims review demonstration is far too burdensome and costly to providers. The group urged Health and Human Services Secretary Tom Price to dump the program before it debuts in Florida and focus on alternative program integrity tools.

The letter may appeal to Price, who sponsored legislation to suspend pre-claims review when he was in the House of Representatives, William Dombi, vice president for law at the National Association for Home Care and Hospice, told me.

The Centers for Medicare & Medicaid Services’ demonstration is scheduled to begin in Florida April 1, and is already underway in Illinois. The three-year program is expected to eventually include Texas, Massachusetts and Michigan. Providers are required to submit a request to Medicare for coverage approval before a final claim can be sent in for payment.

Dombi told me the Illinois pre-claims program has already uncovered numerous flaws. For example, it has increased the workload for home-health providers, he said, forcing them to reassign staff to handle additional paperwork. Illinois home-health agencies have reported as much as a two-month paperwork backlog after just seven months since the program began.

“Alternative, more efficient correctives should be employed in Illinois and nationally rather than continuing the pre-claim review project,” Dombi said.

Joy Cameron, vice president for policy and innovation at the Visiting Nurse Associations of America, told me the pre-claims review program doesn’t deter fraud and said the majority of improper home health payments are due to poor or incomplete documentation.

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