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
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 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.