I 

114TH CONGRESS 

2D SESSION H. R. 6226 

To delay the Medicare demonstration for pre-claim review of home health 

services, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

SEPTEMBER 28, 2016 

Mr. TOM PRICE of Georgia (for himself, Mr. MCGOVERN, Mr. MARCHANT, 

Mr. THORNBERRY, and Mr. GOHMERT) introduced the following bill; 

which was referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of 

such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To delay the Medicare demonstration for pre-claim review 

of home health services, and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Pre-Claims Undermine 

5 Seniors’ Health Act of 2016’’ or the ‘‘PUSH Act of 

6 2016’’. 


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1 SEC. 2. DELAY IN THE MEDICARE DEMONSTRATION FOR 

2 PRE-CLAIM REVIEW OF HOME HEALTH SERV3 ICES. 

4 (a) IN GENERAL.—In the case of the demonstration 

5 for pre-claim review for home health services furnished 

6 under title XVIII of the Social Security Act for operation 

7 in 5 States under section 402(a)(1)(J) of the Social Secu8 rity Amendments of 1967 (42 U.S.C. 1395b–1(a)(1)(J)), 

9 as announced in the Federal Register on June 10, 2016 

10 (81 Fed. Reg. 37598)— 

11 (1) in the case of any of such 5 States in which 

12 the demonstration began operation before the date 

13 of the enactment of this section, the Secretary of 

14 Health and Human Services shall suspend the oper15 ation of the demonstration in such State so it does 

16 not apply to episodes of care beginning earlier than 

17 the later of— 

18 (A) 1 year after such date of enactment; or 

19 (B) 6 months after the date that the Con20 gress receives the report submitted under sub21 section (b); 

22 (2) in the case of any of such 5 States not de23 scribed in paragraph (1), the Secretary shall delay 

24 any operation of the demonstration in each State so 

25 it does not apply to episodes of care beginning ear26 lier than the later of— 


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1 (A) 1 year after the earliest date that such 

2 demonstration was scheduled to begin operation 

3 in the State as so announced; or 

4 (B) 6 months after the date the Congress 

5 receives such report; and 

6 (3) in the case of a State not described in para7 graph (1) or (2), the Secretary shall not begin oper8 ation of such a demonstration in the State until at 

9 least the later of— 

10 (A) 1 year after such date of enactment; or 

11 (B) 6 months after the date that the Con12 gress receives such report. 

13 (b) REPORT.—Not later than 1 year after the date 

14 of the enactment of this Act, the Secretary shall submit 

15 a report to Congress on Medicare pre-claim review of home 

16 health services. The report shall include at least the fol17 lowing: 

18 (1) A comprehensive analysis and description of 

19 the impact of Medicare pre-claim review of home 

20 health services in any State in which it had been im21 plemented before the date of the enactment of this 

22 Act, including its impact on Medicare beneficiaries, 

23 home health agencies, physicians, and Medicare ad24 ministrative costs and the data described in para25 graph (5). 


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1 (2) A detailed description of the resources used 

2 by home health agencies, physicians, and the De3 partment of Health and Human Services and its 

4 contractors in conducting such pre-claim review. 

5 (3) A description of alternative measures that 

6 can be taken to identify the nature of improper pay7 ments in Medicare home health services, the root 

8 cause for such improper payments, and possible cor9 rective actions (other than the use of pre-claim re10 view) that can be taken. 

11 (4) Detailed data on the claims subject to, and 

12 the result of, Medicare pre-claim review conducted 

13 before the date of the enactment of this Act, includ14 ing the following: 

15 (A) The number of pre-claim submissions 

16 and resubmissions. 

17 (B) The percentage of responses to such 

18 submissions and resubmissions that— 

19 (i) fully approve (or affirm) such serv20 ices; 

21 (ii) fully disapprove (or non-affirm) 

22 such services; or 

23 (iii) do not fully approve (or affirm), 

24 or fully disapprove (or non-affirm), such 

25 services. 


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1 (C) Changes in utilization of and spending 

2 on Medicare-covered home health services, inpa3 tient hospital care, and skilled nursing facility 

4 services. 

5 (D) The number of home health agencies 

6 in States where such pre-claim review occurred. 

7 (E) The average dollar amount per claim 

8 and aggregate amount involved in such reviews, 

9 based on the types of responses described in 

10 subparagraph (B). 

11 (F) The 50 diagnosis codes that were most 

12 frequently subject to review. 

13 (G) The proportion of cases subject to re14 view that were post-acute care. 

15 (H) The impact of the review on patient 

16 access to home health services. 

17 (I) The impact of the review on the con18 tinuity of care, including the proportion of cases 

19 that result in a disruption or delay in patient 

20 care. 

Æ 


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