Entrance to the U.S. Department of Health and Human Services headquarters in Washington in February 2025. Archive photograph, not a California home-health provider. Photo: G. Edward Johnson / Wikimedia Commons. Resized under CC BY 4.0.
Medicare is moving toward tougher claims checks for California home-health agencies, asking for emergency approval of paperwork changes needed to expand its Review Choice Demonstration. The request is a step toward expansion, not an announcement that the new reviews have begun.
In a notice filed Friday for public inspection, the Centers for Medicare & Medicaid Services said normal approval procedures could prolong harm from fraud in California’s traditional Medicare home-health benefit. The agency cited payments for care never delivered, potentially unnecessary services and losses to the Medicare trust funds.
The demonstration checks whether home-health claims meet Medicare payment requirements. It uses review before a claim is submitted for payment or after payment has been made. The request concerns Medicare home-health services, not nursing-home inspections or a new restriction on who qualifies for home care.
What agencies would need to prepare for
The notice describes two main choices for participating providers: review of all claims before submission or review of all claims after payment. Agencies remain subject to a review method until they reach the required affirmation or approval rate. Those that meet the target can qualify for relief from most reviews, with spot checks continuing.
The document also describes an alternative for agencies that decline both full-review options: they can submit home-health claims without those reviews but face a 25% payment reduction and possible Recovery Audit Contractor review. That is a payment consequence for providers under the demonstration, not a newly announced 25% reduction in every California patient’s benefits.
Under pre-claim review, an agency sends the Medicare contractor its request and supporting records before submitting the final payment claim. Under post-payment review, the contractor requests records after a claim has been paid to determine whether payment was appropriate.
What has not been decided
CMS is seeking emergency clearance from the Office of Management and Budget for a revision to the information collection, identified as CMS-10599 and OMB control number 0938-1311. The public-inspection notice does not give a California implementation date. It should not be read as confirmation that approval has been granted or that agencies must switch review methods immediately.
The notice is scheduled for Federal Register publication on November 2. It calls for a 14-day public-comment period, with the calendar deadline still left as a placeholder in the unpublished document. Providers should check the final published notice and subsequent CMS instructions rather than assume a start date or comment deadline.
For California operators, the immediate issue is readiness: identify who maintains the clinical records supporting each claim and how those records can be supplied to a Medicare contractor. The notice’s fraud concerns are agency-wide reasons for seeking expansion, not findings against every California home-health agency.
JBizNews Desk | Washington
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