Illinois testing new program to reduce Medicare fraud

Illinois is the first state to participate in a new Centers for Medicare & Medicaid Services program for home health agencies that aims to prevent Medicare fraud, protect patients and minimize the burden on medical providers.

The program, called the Review Choice Demonstration for Home Health Services, was created to test whether choosing from three claim review options reduces fraud in the state among organizations that provide skilled nursing services to Medicare beneficiaries, according to CMS.

Ohio, North Carolina, Florida and Texas will soon participate in the program, as well. The five states were selected because they have “known areas of fraudulent behavior and had either a high home health improper payment rate or a high denial rate,” CMS said in a statement last year.

Between April 17 and May 16, home health agencies in Illinois that submit claims to the Medicare administrative contractor Palmetto GBA can choose from three claim review options: a pre-claim review that occurs after services start, but before submitting the final claim; a post-payment review that occurs after the claim has been processed; or a post-payment option without consistent reviews, which includes a 25 percent reduction in payment.

Agencies that don’t make a selection will automatically be placed in post-payment review. The program officially begins June 1.

Home health agencies will be monitored every six months. Those that demonstrate compliance will have additional claim review choices, including relief from most reviews.

“We expect this demonstration to keep dollars in the Medicare program and away from unscrupulous providers,” CMS Administrator Seema Verma said in a statement today. “We look forward to home health agencies across the Prairie State being a part of this important step in improving Medicare, protecting patients, and safeguarding taxpayer dollars.”

https://www.modernhealthcare.com/government/illinois-testing-new-program-reduce-medicare-fraud