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CMS Issues Change Requests (CR) Regarding Duplicate Claim Reviews and Suspension of Payments

Posted on Thursday, September 15, 2016 1:37 PM

The Centers for Medicare & Medicaid Services (CMS) announced a Change Request (CR) 9665 that does not allow Medicare to post payment review contractors from carrying out duplicative claims reviews.

In response to a U.S. Government Accountability Office (GAO) report 14-474, a CR request is being issued to prove that CMS does not have the bandwidth to prevent post payment review contractors from duplicating claim reviews.

A CR 9396 was also issued by CMS to revise payment suspension procedures directed by the ZPIC.

If a home health agency receives approval for a payment suspension, then all Requests for Anticipated Payments (RAPs) are to be forbidden in accordance with 42 C.F.R. §409.43(c)(2). Then, the ZPIC is supposed to make the request to the CMS Center for Program Integrity.

In the event that ZPIC determines a RAP suppression is needed, then they are encouraged to submit the following information to CMS:
• Are final bills being submitted by the HHA? Yes or No?
• Specify the volume (dollar and number of claims) of RAPs for the past 12 months
• A summary supporting the request for RAP suppression

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