Progress | Impact

Stand Out & Deliver

In May 2016, CMS approved Palmetto GBA to pilot a Home Health Pre-Claim Review demonstration project to conduct pre-claim medical review of all home health claims in Illinois, Texas and Florida as an augmentation to Palmetto’s Jurisdiction M A/B MAC contract.


The Challenge

Given extensive evidence of fraud and abuse in the Medicare home health program, we needed a process by which to achieve the following goals:

  • Ensure that applicable coverage and coding rules are met before the final claim is submitted.

  • Reduce the current program’s reliance on the practice of “pay and chase” for inappropriate billing.

  • Test improved methods for identifying, investigating, and prosecuting Medicare fraud occurring in the home health program while maintaining or improving the quality of care provided to Medicare beneficiaries.

Medicare Improper Payment Rate for Home Health Services


The Medicare improper payment rate for home health services increased from 17.3 percent in 2013 to 51.4 percent in 2014. The fiscal year 2015 HHS Agency Financial Report reported a further increase to 59 percent in 2015.

Our Solution

Palmetto GBA successfully:

  • Completed program start up in 73 days, including recruitment and staffing of more than 430 employees, developing necessary work processes, and implementing innovative technology to support the initiative

  • Conducted extensive provider outreach and education

  • Developed innovative approach to the submission of medical documentation via eServices portal


The Impact

The HH Pre-Claim Review demonstration effectively educated providers to properly submit home health claims. The result was a steady increase in fully approved PCR requests.  In week 22, which ended on December 31, 2016, the majority (87.2 percent) of pre-claim review requests received a fully approved decision. Overall in week 22, 90.8 percent of pre-claim review requests received a provisionally approved or partially approved decision.

Percentage Rate of Approved Requests - Illinois

Percentage / Week


Medicare Integrity Program

Our program safeguard activities resulted in significant savings for Medicare.

Hover over acronyms to reveal full names


Jurisdiction N A/B Medicare Administrative Contractor


Railroad Board Specialty Medicare Administrative Contractor


Benefits Integrity

n/a $1,389,033

Medicare Secondary Payer

$551,252,796 $5,796,496

Medical Review

$501,732,833 $14,088,135
MR Ambulance Prior Auth

Medical Review Ambulance Prior Authorization

$59,156,846 n/a
Total $1,112,142,475 $21,273,664

$1.1 bil

2016 Medicare Program Savings


Request for Advance Payment Suppression Process

Palmetto GBA’s innovative Request for Advance Payment (RAP) suppression process continues to produce savings for the Medicare Program. In 2016, this innovation produced suppression of 27,063 RAPs for which final claims were never submitted. Using an average RAP of $1,650.70, the RAP suppression innovation resulted in $44.6 million in savings for the Medicare program in 2016.

$44.6 mil

2016 Savings



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