81_FR_37710 81 FR 37598 - Medicare Program; Pre-Claim Review Demonstration for Home Health Services

81 FR 37598 - Medicare Program; Pre-Claim Review Demonstration for Home Health Services

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

Federal Register Volume 81, Issue 112 (June 10, 2016)

Page Range37598-37600
FR Document2016-13755

This notice announces a 3-year Medicare pre-claim review demonstration for home health services in the states of Illinois, Florida, Texas, Michigan, and Massachusetts where there have been high incidences of fraud and improper payments for these services.

Federal Register, Volume 81 Issue 112 (Friday, June 10, 2016)
[Federal Register Volume 81, Number 112 (Friday, June 10, 2016)]
[Notices]
[Pages 37598-37600]
From the Federal Register Online  [www.thefederalregister.org]
[FR Doc No: 2016-13755]


-----------------------------------------------------------------------

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-6069-N]


Medicare Program; Pre-Claim Review Demonstration for Home Health 
Services

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Notice.

-----------------------------------------------------------------------

SUMMARY: This notice announces a 3-year Medicare pre-claim review 
demonstration for home health services in the states of Illinois, 
Florida, Texas, Michigan, and Massachusetts where there have been high 
incidences of fraud and improper payments for these services.

DATES: This demonstration will begin in Illinois no earlier than August 
1, 2016, in Florida no earlier than October 1, 2016, and in Texas no 
earlier than December 1, 2016. The demonstration will begin in Michigan 
and Massachusetts no earlier than January 1, 2017.

FOR FURTHER INFORMATION CONTACT: Jennifer McMullen, (410) 786-7635.
    Questions regarding the Medicare Pre-Claim Review Demonstration for 
Home Health Services should be sent to [email protected].

SUPPLEMENTARY INFORMATION:

I. Background and Legislative Authority

    Section 402(a)(1)(J) of the Social Security Amendments of 1967 (42 
U.S.C. 1395b-1(a)(1)(J)) authorizes the Secretary to develop 
demonstration projects that ``develop or demonstrate improved methods 
for the investigation and prosecution of fraud in the provision of care 
or services under the health programs established by the Social 
Security Act'' (the Act). According to this authority, we will 
implement a Medicare demonstration that establishes a pre-claim review 
process for home health agencies (HHAs) to assist in developing 
improved procedures for the identification, investigation, and 
prosecution of Medicare fraud occurring among HHAs providing services 
to Medicare beneficiaries. The proposed demonstration will begin in 
Illinois not earlier than August 1, 2016, will begin in Florida not 
earlier than October 1, 2016, and will begin in Texas not earlier than 
December 1, 2016. The demonstration will begin in Michigan and 
Massachusetts not earlier than January 1, 2017. Providers in each state 
will be notified by the appropriate Medicare Administrative Contractor 
prior to the start of the demonstration in the state. Additionally, CMS 
will utilize other educational efforts to announce the program to 
stakeholders.
    This demonstration will evaluate an additional method that may 
assist with the investigation and prosecution of fraud in order to 
protect the Medicare Trust Funds from fraudulent actions and improper 
payments. We believe this demonstration will bolster the efforts that 
CMS and its partners have taken in implementing a series of anti-fraud 
initiatives in these states and will provide valuable data that CMS 
working with its law enforcement partners, can use to combat the 
submission of fraudulent claims to the Medicare program. One such anti-
fraud initiative is the use of temporary moratoria on the enrollment of 
new home health providers that were put in place in the Miami and 
Chicago that and were subsequently expanded to the Fort Lauderdale, 
Detroit, Dallas, and Houston metropolitan areas. These temporary 
moratoria prohibit the new enrollment of home health providers to help 
CMS prevent and combat fraud, waste, and abuse in these locations.
    We also believe the data collected from this demonstration will 
assist with a second initiative, the Health Care Fraud Prevention and 
Enforcement Action Team (HEAT) Task Force, created by the Department of 
Health and Human Services and the Department of Justice (DOJ), and the 
Heat Task Force's ongoing fight against Medicare fraud. The HEAT Task 
Force uses resources across the government to help prevent and stop 
fraud, waste, and abuse in the Medicare and Medicaid programs. Since 
2007, the HEAT Task Force of the DOJ has charged more than 2,300 
defendants with defrauding Medicare of more than $7 billion and 
convicted approximately 1,800 defendants of felony health care fraud 
offenses. In addition, the data resulting from this demonstration could 
provide investigators and law enforcement with important information to 
determine how to focus their investigation activities to identify and 
combat home health fraud, and in so doing, protect the Medicare Trust 
Funds from fraudulent actions and improper payments.
    This demonstration may also help prevent improper payments in 
geographic areas where HHA providers are known to have a high incidence 
of fraud. The improper payment rate for HHA claims has been increasing 
over the past several years, and fraud is one factor contributing to 
the increase. It is important to note that while all payments made as a 
result of fraud are considered ``improper payments,'' not all improper 
payments constitute fraud. CMS' Comprehensive Error Rate Testing (CERT) 
program, which measures Medicare's improper payment rate, estimates the 
payments that did not meet Medicare coverage, coding, and billing 
rules. The fiscal year (FY) 2015 Department of Health and Human 
Services Agency Financial Report reported that the CERT program's 
calculated 2015 improper payment rate for HHA claims increased to 59.0 
percent from the 2014 rate of 51.4 percent and the 2013 rate of 17.3 
percent. The increase in the 2015 improper payment rate was primarily 
due to ``insufficient documentation'' errors, specifically, 
insufficient documentation to support the medical necessity of the 
services. Similar documentation errors have also occurred in previous 
years. For example, the 2014 CERT report found that the majority of 
home health payment errors occurred when the narrative portion of the 
face-to-face encounter documentation did not sufficiently describe how 
the clinical findings from the encounter supported the beneficiary's 
homebound status and need for skilled services.
    Due to the substantial increase in improper payments and concerns 
raised by the home health industry, relating to implementation of the 
face-to-face encounter documentation requirement, we made Medicare HHA 
payment policy changes in an effort to simplify the face-to-face 
encounter regulations. Specifically, as of January 1, 2015, a separate 
narrative is no longer required as part of the face-to-face 
documentation. Rather, the certifying physician's or the acute/post-
acute care facility's medical record(s) for the patient must contain 
sufficient documentation to substantiate eligibility for home health 
services.
    Despite these recent changes, we continue to see cases in which the 
medical record does not support eligibility for the home health 
benefit, which constitute ``insufficient documentation'' errors. 
Moreover, we note that the recent regulatory changes do not address HHA 
errors in home health billing other than those related to the face-to-
face narrative requirement.

[[Page 37599]]

Therefore, we also plan to use this demonstration to help make sure 
that all coverage and clinical documentation requirements are met 
before claims are submitted for final payment.
    We also believe that this demonstration will enable us to--(1) test 
the level of resources needed to implement a permanent pre-claim review 
program for home health services; (2) determine the feasibility of 
performing pre-claim reviews to prevent payment for services that have 
historically had a high incidence of fraud; and (3) determine the 
return on investment of pre-claim review for home health claims. This 
demonstration will support our program integrity strategy of moving 
beyond a reactive ``pay and chase'' method toward a more effective, 
proactive strategy that identifies potential improper payments before 
payments are made. We will analyze data from the home health services 
pre-claim review demonstration to evaluate the impact on fraud in the 
demonstration states, which we believe will help assist in developing 
improved procedures for the identification, investigation, and 
prosecution of Medicare fraud occurring among HHAs providing services 
to Medicare beneficiaries and may consider if a more focused, risk 
based approach to pre-claim review is warranted in the future.
    The pre-claim review demonstration does not create new 
documentation requirements, but simply requires currently mandated 
documentation earlier in the claims payment process. In addition, there 
are no changes to the home health service benefit for Medicare fee-for 
service beneficiaries.

II. Provisions of the Notice

    This demonstration will implement a 3-year pre-claim review process 
for home health services in Illinois, Florida, Texas, Michigan, and 
Massachusetts. Prior to and during the demonstration, we will conduct 
outreach to and education of home health providers and Medicare 
beneficiaries using media such as webinars, open door forums, 
frequently asked questions pages on our Web site, other Web site 
postings, and educational materials issued by the Medicare 
Administrative Contractors (MACs) to provide guidance on the pre-claim 
review process. Additional information about the implementation of the 
pre-claim review demonstration will be available on the CMS Web site 
at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Overview.html. 
Questions regarding the Medicare Pre-Claim Review Demonstration for 
Home Health Services should be sent to [email protected]. 
Under this demonstration, a HHA provider, the entity billing on behalf 
of the HHA, or the beneficiary (known as the ``submitter'') will be 
encouraged to submit to the relevant MAC a request for pre-claim 
review, along with all relevant documentation to support Medicare 
coverage of the applicable home health level of service. After receipt 
of all relevant documentation, the MAC will review the pre-claim review 
request to determine whether the service level complies with applicable 
Medicare coverage and clinical documentation requirements. The HHA 
provider should submit the Request for Anticipated Payment (RAP) before 
submitting the pre-claim review request and begin providing services 
while waiting for the decision from the MAC.
    The MAC will communicate to the HHA and beneficiary a decision 
provisionally approving (or disapproving) payment after a submission of 
a request for pre-claim review. For the initial submission of a pre-
claim review request, the MAC will make all reasonable efforts to make 
a determination and issue a notice of the decision within 10 business 
days.
    If the MAC declines payment after review, the submitter may amend 
and resubmit it. A pre-claim review request may be resubmitted an 
unlimited number of times. For subsequent pre-claim review requests, 
CMS or its agents will conduct a complex medical review and make all 
reasonable efforts to postmark and notify the HHA and the beneficiary 
of its decision within 20 business days. These timeframes are 
consistent with the Prior Authorization of Power Mobility Devices 
(PMDs) Demonstration. Meeting these timeframes will be part of the 
contract performance metrics for the MACs that are involved in this 
demonstration at the time their contracts are modified to incorporate 
the demonstration's work requirements (as well as the necessary 
funding).
    If an applicable claim is submitted for payment without a pre-claim 
review decision, it will be stopped for prepayment review and 
documentation will be requested. After the first 3 months of the 
demonstration in a particular state, we will apply a payment reduction 
for claims that, after such prepayment review, are deemed payable, but 
did not first receive a pre-claim review decision. As evidence of 
compliance, the HHA must submit the pre-claim review number on the 
claim in order to avoid a 25-percent payment reduction. The 25-percent 
payment reduction cannot be recouped from or otherwise charged to the 
beneficiary, and is not subject to appeal. The beneficiary would not be 
liable for more than he or she would otherwise be if the demonstration 
were not in place.
    The following explains the various pre-claim review scenarios:
    In each of the following scenarios, the HHA would conduct all 
required assessments, submit the RAP, and begin services for the 
beneficiaries.
     Scenario 1: When a submitter submits a pre-claim review 
request to the MAC with appropriate documentation, and all relevant 
Medicare coverage and documentation requirements are met for the home 
health service, the MAC will send a provisional affirmative pre-claim 
review decision to the HHA and the Medicare beneficiary. When the HHA 
submits the claim for payment to the MAC after delivering the home 
health level of service(s), the claim will include a unique tracking 
number that indicates it has been affirmed for pre-claim review and, as 
long as all Medicare coverage and documentation requirements continue 
to be met, the claim is paid.
     Scenario 2: When a submitter submits a pre-claim review 
request with documentation that does not meet all relevant Medicare 
coverage and clinical documentation requirements for the home health 
level of service, notification of a non-affirmative decision will be 
sent to the HHA and the beneficiary advising them that Medicare will 
not pay for the service. The submitter may then resubmit the request 
with additional documentation to support that the Medicare requirements 
have been met. Alternatively, the HHA could submit the claim to the 
MAC, at which point the MAC would deny the claim for lack of a 
provisional affirmative pre-claim review decision and recoup the 
payment made on the RAP following their standard procedures. Upon 
receiving the claim denial by the MAC, the HHA or the beneficiary would 
have the opportunity to appeal the claim denial if they believe 
Medicare coverage was denied inappropriately. Beneficiaries will 
continue to have the option of signing an Advance Beneficiary Notice of 
Noncoverage (ABN) in order to receive the services and be liable for 
payment.
     Scenario 3: When a submitter submits a pre-claim review 
request with incomplete documentation, the request, along with a 
detailed decision letter explaining what information is missing, is 
sent back to the submitter for resubmission. Both the HHA and the 
beneficiary are notified and the

[[Page 37600]]

submitter can resubmit the request with appropriate supporting 
documentation.
     Scenario 4: When the HHA provides the treatment to the 
beneficiary and submits the claim to the MAC for payment without 
submitting a pre-claim review request, the home health claim will be 
stopped for prepayment review and documentation will be requested. If 
the claim is determined to be not medically necessary or not 
sufficiently documented, the claim will be denied and all current 
policies and procedures regarding liability for payment will apply. The 
HHA, the beneficiary, or both can appeal the claim denial if they 
believe the claim was payable. If the claim is determined to be payable 
on appeal, it will be paid. After the first 3 months of the 
demonstration, we will reduce payment by 25 percent for claims that 
after such prepayment review are deemed payable but did not first 
receive a pre-claim review decision. This payment reduction is not 
subject to appeal. After a claim is submitted, processed, and denied, 
appeal rights for the claim denial would become available in accordance 
with 42 CFR part 405, subpart I. The 25-percent payment reduction 
cannot be charged to the beneficiary. The beneficiary would not be 
liable for more than he or she would otherwise be if the demonstration 
were not in place.
    Additional information is available on the CMS' Web site at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Overview.html.

III. Collection of Information Requirements

    We announced and solicited comments for the information collection 
requirements associated with the Medicare Prior Authorization of Home 
Health Services Demonstration in a 60-day Federal Register notice that 
published on February 5, 2016 (81 FR 6275). The information collection 
requirements do not take effect until they are approved by OMB and 
issued a valid OMB control number.

    Dated: May 26, 2016.
Andrew M. Slavitt,
Acting Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2016-13755 Filed 6-8-16; 4:15 pm]
 BILLING CODE 4120-01-P



                                                    37598                           Federal Register / Vol. 81, No. 112 / Friday, June 10, 2016 / Notices

                                                    comments will become a matter of                        Medicare beneficiaries. The proposed                      This demonstration may also help
                                                    public record.                                          demonstration will begin in Illinois not               prevent improper payments in
                                                                                                            earlier than August 1, 2016, will begin                geographic areas where HHA providers
                                                    Sharon B. Arnold,
                                                                                                            in Florida not earlier than October 1,                 are known to have a high incidence of
                                                    Deputy Director.                                        2016, and will begin in Texas not earlier              fraud. The improper payment rate for
                                                    [FR Doc. 2016–13841 Filed 6–9–16; 8:45 am]              than December 1, 2016. The                             HHA claims has been increasing over
                                                    BILLING CODE 4160–90–P                                  demonstration will begin in Michigan                   the past several years, and fraud is one
                                                                                                            and Massachusetts not earlier than                     factor contributing to the increase. It is
                                                                                                            January 1, 2017. Providers in each state               important to note that while all
                                                    DEPARTMENT OF HEALTH AND                                will be notified by the appropriate                    payments made as a result of fraud are
                                                    HUMAN SERVICES                                          Medicare Administrative Contractor                     considered ‘‘improper payments,’’ not
                                                                                                            prior to the start of the demonstration in             all improper payments constitute fraud.
                                                    Centers for Medicare & Medicaid
                                                                                                            the state. Additionally, CMS will utilize              CMS’ Comprehensive Error Rate Testing
                                                    Services
                                                                                                            other educational efforts to announce                  (CERT) program, which measures
                                                    [CMS–6069–N]                                            the program to stakeholders.                           Medicare’s improper payment rate,
                                                                                                               This demonstration will evaluate an                 estimates the payments that did not
                                                    Medicare Program; Pre-Claim Review                      additional method that may assist with                 meet Medicare coverage, coding, and
                                                    Demonstration for Home Health                           the investigation and prosecution of                   billing rules. The fiscal year (FY) 2015
                                                    Services                                                fraud in order to protect the Medicare                 Department of Health and Human
                                                    AGENCY: Centers for Medicare &                          Trust Funds from fraudulent actions                    Services Agency Financial Report
                                                    Medicaid Services (CMS), HHS.                           and improper payments. We believe this                 reported that the CERT program’s
                                                                                                            demonstration will bolster the efforts                 calculated 2015 improper payment rate
                                                    ACTION: Notice.
                                                                                                            that CMS and its partners have taken in                for HHA claims increased to 59.0
                                                    SUMMARY:   This notice announces a 3-                   implementing a series of anti-fraud                    percent from the 2014 rate of 51.4
                                                    year Medicare pre-claim review                          initiatives in these states and will                   percent and the 2013 rate of 17.3
                                                    demonstration for home health services                  provide valuable data that CMS working                 percent. The increase in the 2015
                                                    in the states of Illinois, Florida, Texas,              with its law enforcement partners, can                 improper payment rate was primarily
                                                    Michigan, and Massachusetts where                       use to combat the submission of                        due to ‘‘insufficient documentation’’
                                                    there have been high incidences of fraud                fraudulent claims to the Medicare                      errors, specifically, insufficient
                                                    and improper payments for these                         program. One such anti-fraud initiative                documentation to support the medical
                                                    services.                                               is the use of temporary moratoria on the               necessity of the services. Similar
                                                                                                            enrollment of new home health                          documentation errors have also
                                                    DATES: This demonstration will begin in
                                                                                                            providers that were put in place in the                occurred in previous years. For
                                                    Illinois no earlier than August 1, 2016,                Miami and Chicago that and were                        example, the 2014 CERT report found
                                                    in Florida no earlier than October 1,                   subsequently expanded to the Fort                      that the majority of home health
                                                    2016, and in Texas no earlier than                      Lauderdale, Detroit, Dallas, and                       payment errors occurred when the
                                                    December 1, 2016. The demonstration                     Houston metropolitan areas. These                      narrative portion of the face-to-face
                                                    will begin in Michigan and                              temporary moratoria prohibit the new                   encounter documentation did not
                                                    Massachusetts no earlier than January 1,                enrollment of home health providers to                 sufficiently describe how the clinical
                                                    2017.                                                   help CMS prevent and combat fraud,                     findings from the encounter supported
                                                    FOR FURTHER INFORMATION CONTACT:                        waste, and abuse in these locations.                   the beneficiary’s homebound status and
                                                    Jennifer McMullen, (410) 786–7635.                         We also believe the data collected                  need for skilled services.
                                                       Questions regarding the Medicare Pre-                from this demonstration will assist with                  Due to the substantial increase in
                                                    Claim Review Demonstration for Home                     a second initiative, the Health Care                   improper payments and concerns raised
                                                    Health Services should be sent to                       Fraud Prevention and Enforcement                       by the home health industry, relating to
                                                    HHPreClaimDemo@cms.hhs.gov.                             Action Team (HEAT) Task Force,                         implementation of the face-to-face
                                                    SUPPLEMENTARY INFORMATION:                              created by the Department of Health and                encounter documentation requirement,
                                                                                                            Human Services and the Department of                   we made Medicare HHA payment
                                                    I. Background and Legislative
                                                                                                            Justice (DOJ), and the Heat Task Force’s               policy changes in an effort to simplify
                                                    Authority
                                                                                                            ongoing fight against Medicare fraud.                  the face-to-face encounter regulations.
                                                       Section 402(a)(1)(J) of the Social                   The HEAT Task Force uses resources                     Specifically, as of January 1, 2015, a
                                                    Security Amendments of 1967 (42                         across the government to help prevent                  separate narrative is no longer required
                                                    U.S.C. 1395b–1(a)(1)(J)) authorizes the                 and stop fraud, waste, and abuse in the                as part of the face-to-face
                                                    Secretary to develop demonstration                      Medicare and Medicaid programs. Since                  documentation. Rather, the certifying
                                                    projects that ‘‘develop or demonstrate                  2007, the HEAT Task Force of the DOJ                   physician’s or the acute/post-acute care
                                                    improved methods for the investigation                  has charged more than 2,300 defendants                 facility’s medical record(s) for the
                                                    and prosecution of fraud in the                         with defrauding Medicare of more than                  patient must contain sufficient
                                                    provision of care or services under the                 $7 billion and convicted approximately                 documentation to substantiate eligibility
                                                    health programs established by the                      1,800 defendants of felony health care                 for home health services.
                                                    Social Security Act’’ (the Act).                        fraud offenses. In addition, the data                     Despite these recent changes, we
                                                    According to this authority, we will                    resulting from this demonstration could                continue to see cases in which the
asabaliauskas on DSK3SPTVN1PROD with NOTICES




                                                    implement a Medicare demonstration                      provide investigators and law                          medical record does not support
                                                    that establishes a pre-claim review                     enforcement with important information                 eligibility for the home health benefit,
                                                    process for home health agencies                        to determine how to focus their                        which constitute ‘‘insufficient
                                                    (HHAs) to assist in developing                          investigation activities to identify and               documentation’’ errors. Moreover, we
                                                    improved procedures for the                             combat home health fraud, and in so                    note that the recent regulatory changes
                                                    identification, investigation, and                      doing, protect the Medicare Trust Funds                do not address HHA errors in home
                                                    prosecution of Medicare fraud occurring                 from fraudulent actions and improper                   health billing other than those related to
                                                    among HHAs providing services to                        payments.                                              the face-to-face narrative requirement.


                                               VerDate Sep<11>2014   19:02 Jun 09, 2016   Jkt 238001   PO 00000   Frm 00033   Fmt 4703   Sfmt 4703   E:\FR\FM\10JNN1.SGM   10JNN1


                                                                                    Federal Register / Vol. 81, No. 112 / Friday, June 10, 2016 / Notices                                            37599

                                                    Therefore, we also plan to use this        Services should be sent to                                          otherwise charged to the beneficiary,
                                                    demonstration to help make sure that all   HHPreClaimDemo@cms.hhs.gov. Under                                   and is not subject to appeal. The
                                                    coverage and clinical documentation        this demonstration, a HHA provider, the                             beneficiary would not be liable for more
                                                    requirements are met before claims are     entity billing on behalf of the HHA, or                             than he or she would otherwise be if the
                                                    submitted for final payment.               the beneficiary (known as the                                       demonstration were not in place.
                                                       We also believe that this               ‘‘submitter’’) will be encouraged to                                   The following explains the various
                                                    demonstration will enable us to—(1) test   submit to the relevant MAC a request for                            pre-claim review scenarios:
                                                    the level of resources needed to           pre-claim review, along with all relevant                              In each of the following scenarios, the
                                                    implement a permanent pre-claim            documentation to support Medicare                                   HHA would conduct all required
                                                    review program for home health             coverage of the applicable home health                              assessments, submit the RAP, and begin
                                                    services; (2) determine the feasibility of level of service. After receipt of all                              services for the beneficiaries.
                                                    performing pre-claim reviews to prevent    relevant documentation, the MAC will                                   • Scenario 1: When a submitter
                                                    payment for services that have             review the pre-claim review request to                              submits a pre-claim review request to
                                                    historically had a high incidence of       determine whether the service level                                 the MAC with appropriate
                                                    fraud; and (3) determine the return on     complies with applicable Medicare                                   documentation, and all relevant
                                                    investment of pre-claim review for         coverage and clinical documentation                                 Medicare coverage and documentation
                                                    home health claims. This demonstration     requirements. The HHA provider should                               requirements are met for the home
                                                    will support our program integrity         submit the Request for Anticipated                                  health service, the MAC will send a
                                                    strategy of moving beyond a reactive       Payment (RAP) before submitting the                                 provisional affirmative pre-claim review
                                                    ‘‘pay and chase’’ method toward a more     pre-claim review request and begin                                  decision to the HHA and the Medicare
                                                    effective, proactive strategy that         providing services while waiting for the                            beneficiary. When the HHA submits the
                                                    identifies potential improper payments     decision from the MAC.                                              claim for payment to the MAC after
                                                    before payments are made. We will             The MAC will communicate to the                                  delivering the home health level of
                                                    analyze data from the home health          HHA and beneficiary a decision                                      service(s), the claim will include a
                                                    services pre-claim review demonstration    provisionally approving (or                                         unique tracking number that indicates it
                                                    to evaluate the impact on fraud in the     disapproving) payment after a                                       has been affirmed for pre-claim review
                                                    demonstration states, which we believe     submission of a request for pre-claim                               and, as long as all Medicare coverage
                                                    will help assist in developing improved    review. For the initial submission of a
                                                                                                                                                                   and documentation requirements
                                                    procedures for the identification,         pre-claim review request, the MAC will
                                                                                                                                                                   continue to be met, the claim is paid.
                                                    investigation, and prosecution of          make all reasonable efforts to make a
                                                                                                                                                                      • Scenario 2: When a submitter
                                                    Medicare fraud occurring among HHAs        determination and issue a notice of the
                                                                                                                                                                   submits a pre-claim review request with
                                                    providing services to Medicare             decision within 10 business days.
                                                                                                  If the MAC declines payment after                                documentation that does not meet all
                                                    beneficiaries and may consider if a more
                                                    focused, risk based approach to pre-       review, the submitter may amend and                                 relevant Medicare coverage and clinical
                                                    claim review is warranted in the future.   resubmit it. A pre-claim review request                             documentation requirements for the
                                                       The pre-claim review demonstration      may be resubmitted an unlimited                                     home health level of service,
                                                    does not create new documentation          number of times. For subsequent pre-                                notification of a non-affirmative
                                                    requirements, but simply requires          claim review requests, CMS or its agents                            decision will be sent to the HHA and
                                                    currently mandated documentation           will conduct a complex medical review                               the beneficiary advising them that
                                                    earlier in the claims payment process. In  and make all reasonable efforts to                                  Medicare will not pay for the service.
                                                    addition, there are no changes to the      postmark and notify the HHA and the                                 The submitter may then resubmit the
                                                    home health service benefit for            beneficiary of its decision within 20                               request with additional documentation
                                                    Medicare fee-for service beneficiaries.    business days. These timeframes are                                 to support that the Medicare
                                                                                               consistent with the Prior Authorization                             requirements have been met.
                                                    II. Provisions of the Notice                                                                                   Alternatively, the HHA could submit
                                                                                               of Power Mobility Devices (PMDs)
                                                       This demonstration will implement a     Demonstration. Meeting these                                        the claim to the MAC, at which point
                                                    3-year pre-claim review process for        timeframes will be part of the contract                             the MAC would deny the claim for lack
                                                    home health services in Illinois, Florida, performance metrics for the MACs that                               of a provisional affirmative pre-claim
                                                    Texas, Michigan, and Massachusetts.        are involved in this demonstration at                               review decision and recoup the
                                                    Prior to and during the demonstration,     the time their contracts are modified to                            payment made on the RAP following
                                                    we will conduct outreach to and            incorporate the demonstration’s work                                their standard procedures. Upon
                                                    education of home health providers and requirements (as well as the necessary                                  receiving the claim denial by the MAC,
                                                    Medicare beneficiaries using media         funding).                                                           the HHA or the beneficiary would have
                                                    such as webinars, open door forums,           If an applicable claim is submitted for                          the opportunity to appeal the claim
                                                    frequently asked questions pages on our payment without a pre-claim review                                     denial if they believe Medicare coverage
                                                    Web site, other Web site postings, and     decision, it will be stopped for                                    was denied inappropriately.
                                                    educational materials issued by the        prepayment review and documentation                                 Beneficiaries will continue to have the
                                                    Medicare Administrative Contractors        will be requested. After the first 3                                option of signing an Advance
                                                    (MACs) to provide guidance on the pre- months of the demonstration in a                                        Beneficiary Notice of Noncoverage
                                                    claim review process. Additional           particular state, we will apply a                                   (ABN) in order to receive the services
                                                    information about the implementation       payment reduction for claims that, after                            and be liable for payment.
asabaliauskas on DSK3SPTVN1PROD with NOTICES




                                                    of the pre-claim review demonstration      such prepayment review, are deemed                                     • Scenario 3: When a submitter
                                                    will be available on the CMS Web site      payable, but did not first receive a pre-                           submits a pre-claim review request with
                                                    at: https://www.cms.gov/Research-          claim review decision. As evidence of                               incomplete documentation, the request,
                                                    Statistics-Data-and-Systems/Monitoring- compliance, the HHA must submit the                                    along with a detailed decision letter
                                                    Programs/Medicare-FFS-Compliance-          pre-claim review number on the claim                                explaining what information is missing,
                                                    Programs/Overview.html. Questions          in order to avoid a 25-percent payment                              is sent back to the submitter for
                                                    regarding the Medicare Pre-Claim           reduction. The 25-percent payment                                   resubmission. Both the HHA and the
                                                    Review Demonstration for Home Health reduction cannot be recouped from or                                      beneficiary are notified and the


                                               VerDate Sep<11>2014   19:02 Jun 09, 2016   Jkt 238001   PO 00000   Frm 00034   Fmt 4703   Sfmt 4703   E:\FR\FM\10JNN1.SGM   10JNN1


                                                    37600                           Federal Register / Vol. 81, No. 112 / Friday, June 10, 2016 / Notices

                                                    submitter can resubmit the request with                 DEPARTMENT OF HEALTH AND                               Responsibility Education Program
                                                    appropriate supporting documentation.                   HUMAN SERVICES                                         Innovative Strategies (PREIS) program to
                                                       • Scenario 4: When the HHA                                                                                  implement a parent education program
                                                                                                            Administration for Children and                        for Latino youth (Salud y Exito/Health
                                                    provides the treatment to the beneficiary
                                                                                                            Families                                               and Success) and to rigorously evaluate
                                                    and submits the claim to the MAC for
                                                                                                            [CFDA Number: 93.092]                                  the intervention to determine impact on
                                                    payment without submitting a pre-claim
                                                                                                                                                                   reducing sexual risk-taking behavior.
                                                    review request, the home health claim
                                                                                                            Announcing the Intent To Award                         The supplement award will be used to
                                                    will be stopped for prepayment review                                                                          augment dissemination efforts for the
                                                                                                            Single-Source Expansion Supplement
                                                    and documentation will be requested. If                                                                        intervention by developing a social
                                                                                                            Grants to Two Personal Responsibility
                                                    the claim is determined to be not                       Education Program Innovative                           media campaign to promote the
                                                    medically necessary or not sufficiently                 Strategies (PREIS) Grantees                            intervention Web site and to analyze
                                                    documented, the claim will be denied                                                                           social media data to determine the
                                                    and all current policies and procedures                 AGENCY:   Family and Youth Services                    campaign’s reach.
                                                    regarding liability for payment will                    Bureau, ACYF, ACF.
                                                                                                            ACTION: This notice announces the
                                                                                                                                                                     Statutory Authority: The statutory
                                                    apply. The HHA, the beneficiary, or                                                                            authority for the award is Sec. 513 of the
                                                    both can appeal the claim denial if they                intent to award single-source expansion                Social Security Act (42 U.S.C. 713). Sec. 2953
                                                    believe the claim was payable. If the                   supplement grants under the Personal                   of the Patient Protection and Affordable Care
                                                    claim is determined to be payable on                    Responsibility Education Program                       Act of 2010 (Pub. L. 111–148) established
                                                    appeal, it will be paid. After the first 3              Innovative Strategies (PREIS) program to               PREP and funded it for FY 2010 through
                                                    months of the demonstration, we will                    Children’s Hospital of Los Angeles in                  2014. Sec. 206 of the Protecting Access to
                                                                                                            Los Angeles, CA and Education                          Medicare Act of 2014 (Pub. L. 113–93)
                                                    reduce payment by 25 percent for                                                                               extended that funding through FY 2015. Sec.
                                                                                                            Development Center, Inc. in Newton,
                                                    claims that after such prepayment                                                                              215 of the Medicare Access and CHIP
                                                                                                            MA.
                                                    review are deemed payable but did not                                                                          Reauthorization Act of 2015 (Pub. L. 114–10)
                                                    first receive a pre-claim review decision.              SUMMARY:   The Administration for                      extended funding through FY 2017.
                                                    This payment reduction is not subject to                Children and Families (ACF),                           Christopher Beach,
                                                    appeal. After a claim is submitted,                     Administration on Children, Youth and                  Senior Grants Policy Specialist, Division of
                                                    processed, and denied, appeal rights for                Families (ACYF), Family and Youth                      Grants Policy, Office of Administration,
                                                    the claim denial would become                           Services Bureau (FYSB), Adolescent                     Administration for Children and Families.
                                                    available in accordance with 42 CFR                     Pregnancy Prevention Program,                          [FR Doc. 2016–13698 Filed 6–9–16; 8:45 am]
                                                    part 405, subpart I. The 25-percent                     announces its intent to award a single-                BILLING CODE 8414–37–P
                                                    payment reduction cannot be charged to                  source expansion supplement grant of
                                                    the beneficiary. The beneficiary would                  up to $151,265 to Children’s Hospital of
                                                    not be liable for more than he or she                   Los Angeles and up to $55, 917.20 to                   DEPARTMENT OF HEALTH AND
                                                                                                            Education Development Center, Inc.                     HUMAN SERVICES
                                                    would otherwise be if the demonstration
                                                                                                            DATES: The period of support for the
                                                    were not in place.
                                                                                                            single-source expansion supplements is                 Administration for Children and
                                                       Additional information is available on               September 30, 2015, through September                  Families
                                                    the CMS’ Web site at https://                           29, 2016.
                                                    www.cms.gov/Research-Statistics-Data-                      FOR FURTHER INFORMATION CONTACT:                    Submission for OMB Review;
                                                    and-Systems/Monitoring-Programs/                        LeBretia White, Program Manager,                       Comment Request
                                                    Medicare-FFS-Compliance-Programs/                       Adolescent Pregnancy Prevention                          Title: National Survey of Child and
                                                    Overview.html.                                          Program, Division of Adolescent                        Adolescent Well-Being-Third Cohort
                                                                                                            Development and Support, Family and                    (NSCAW III): Agency Recruitment.
                                                    III. Collection of Information                          Youth Services Bureau, 330 C Street
                                                    Requirements                                                                                                     OMB No.: 0970–0202.
                                                                                                            SW., Washington, DC 20201. Telephone:                    Description: The Administration for
                                                      We announced and solicited                            202–205–9605; Email: LeBretia.White@                   Children and Families (ACF) within the
                                                                                                            acf.hhs.gov.                                           U.S. Department of Health and Human
                                                    comments for the information collection
                                                    requirements associated with the                        SUPPLEMENTARY INFORMATION: Children’s                  Services (HHS) intends to collect data
                                                    Medicare Prior Authorization of Home                    Hospital of Los Angeles is funded under                on a third cohort of children and
                                                    Health Services Demonstration in a 60-                  the Personal Responsibility Education                  families for the National Survey of Child
                                                    day Federal Register notice that                        Program Innovative Strategies (PREIS)                  and Adolescent Well-Being (NSCAW).
                                                                                                            program to adapt an existing evidence-                 NSCAW is the only source of nationally
                                                    published on February 5, 2016 (81 FR
                                                                                                            based pregnancy prevention program for                 representative, longitudinal, firsthand
                                                    6275). The information collection
                                                                                                            pregnant and parenting teens and                       information about the functioning and
                                                    requirements do not take effect until
                                                                                                            rigorously evaluate the program for its                well-being, service needs, and service
                                                    they are approved by OMB and issued                     impact on reducing repeat pregnancy.                   utilization of children and families who
                                                    a valid OMB control number.                             The supplemental award will be used to                 come to the attention of the child
                                                      Dated: May 26, 2016.                                  review, code, and analyze digital                      welfare system. The first two cohorts of
                                                                                                            recordings, employ intensive tracking                  NSCAW were collected beginning in
asabaliauskas on DSK3SPTVN1PROD with NOTICES




                                                    Andrew M. Slavitt,
                                                    Acting Administrator, Centers for Medicare              and follow up efforts with participants                1999 and 2008 and studied children
                                                    & Medicaid Services.                                    to administer the 36-month follow-up                   who had been the subject of
                                                    [FR Doc. 2016–13755 Filed 6–8–16; 4:15 pm]
                                                                                                            survey, conduct additional advanced                    investigation by Child Protective
                                                                                                            analyses, develop manuscripts and                      Services. Children were sampled from
                                                    BILLING CODE 4120–01–P
                                                                                                            briefs based on additional analyses, and               child welfare agencies nationwide.
                                                                                                            disseminate study findings.                              The proposed data collection plan for
                                                                                                               Education Development Center, Inc. is               the third cohort of NSCAW includes
                                                                                                            funded under the Personal                              two phases: Phase 1 includes child


                                               VerDate Sep<11>2014   19:02 Jun 09, 2016   Jkt 238001   PO 00000   Frm 00035   Fmt 4703   Sfmt 4703   E:\FR\FM\10JNN1.SGM   10JNN1



Document Created: 2018-02-08 07:35:58
Document Modified: 2018-02-08 07:35:58
CategoryRegulatory Information
CollectionFederal Register
sudoc ClassAE 2.7:
GS 4.107:
AE 2.106:
PublisherOffice of the Federal Register, National Archives and Records Administration
SectionNotices
ActionNotice.
DatesThis demonstration will begin in Illinois no earlier than August 1, 2016, in Florida no earlier than October 1, 2016, and in Texas no earlier than December 1, 2016. The demonstration will begin in Michigan and Massachusetts no earlier than January 1, 2017.
ContactJennifer McMullen, (410) 786-7635.
FR Citation81 FR 37598 

2025 Federal Register | Disclaimer | Privacy Policy
USC | CFR | eCFR