CMS Proposes Program Integrity Demonstration in North Carolina

The Centers for Medicare & Medicaid Services (CMS) has issued a second proposed rule for a 30-day public comment on the Home Health Pre-Claim Review Demonstration. This demonstration seeks to prevent and identify fraud, waste, and abuse in the Medicare home health services through either pre-claim or post-payment review.

The proposed rule calls for a demonstration in five states starting on December 10, 2018 in Illinois. The other states slated to be phased in every 60-90 days include Ohio, North Carolina, Florida, and Texas, with the option of expanding to other states. Providers will have three options: 100% pre-payment review, 100% post-payment review, or a 25% rate reduction and up to 100% reviews by the Recovery Audit Contractor.

Leaders from the Home Health Practice, along with GAO, have submitted formal comments calling for CMS to evaluate and release results from the previous program integrity (PI) demonstration before initiating this new demonstration, and to develop a targeted review approach to PI efforts. BAYADA wants to be a strong partner in rooting out fraud, waste, and abuse, with complete transparency.

Offices should pay close attention to their documentation to ensure referral paperwork, nursing and therapy notes clearly paint the medical necessity picture.  Areas of focus include appropriate documentation pertaining to:

  • Face to face
  • Homebound status
  • Therapy SMART goals
  • Skilled service needs

Questions should be directed to MAG Regional Director Richard Hopson at rhopson@bayada.com.

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