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 addi-
tion to the Committee on Energy and Commerce, for a period to be sub-
sequently 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. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Pre-Claims Undermine 
Seniors’ Health Act of 2016’’ or the ‘‘PUSH Act of 
2016’’. 
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SEC. 2. DELAY IN THE MEDICARE DEMONSTRATION FOR 
PRE-CLAIM REVIEW OF HOME HEALTH SERV-
ICES. 
(a) IN GENERAL.—In the case of the demonstration 
for pre-claim review for home health services furnished 
under title XVIII of the Social Security Act for operation 
in 5 States under section 402(a)(1)(J) of the Social Secu-
rity Amendments of 1967 (42 U.S.C. 1395b–1(a)(1)(J)), 
as announced in the Federal Register on June 10, 2016 
(81 Fed. Reg. 37598)— 
(1) in the case of any of such 5 States in which 
the demonstration began operation before the date 
of the enactment of this section, the Secretary of 
Health and Human Services shall suspend the oper-
ation of the demonstration in such State so it does 
not apply to episodes of care beginning earlier than 
the later of— 
(A) 1 year after such date of enactment; or 
(B) 6 months after the date that the Con-
gress receives the report submitted under sub-
section (b); 
(2) in the case of any of such 5 States not de-
scribed in paragraph (1), the Secretary shall delay 
any operation of the demonstration in each State so 
it does not apply to episodes of care beginning ear-
lier than the later of— 
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(A) 1 year after the earliest date that such 
demonstration was scheduled to begin operation 
in the State as so announced; or 
(B) 6 months after the date the Congress 
receives such report; and 
(3) in the case of a State not described in para-
graph (1) or (2), the Secretary shall not begin oper-
ation of such a demonstration in the State until at 
least the later of— 
(A) 1 year after such date of enactment; or 
(B) 6 months after the date that the Con-
gress receives such report. 
(b) REPORT.—Not later than 1 year after the date 
of the enactment of this Act, the Secretary shall submit 
a report to Congress on Medicare pre-claim review of home 
health services. The report shall include at least the fol-
lowing: 
(1) A comprehensive analysis and description of 
the impact of Medicare pre-claim review of home 
health services in any State in which it had been im-
plemented before the date of the enactment of this 
Act, including its impact on Medicare beneficiaries, 
home health agencies, physicians, and Medicare ad-
ministrative costs and the data described in para-
graph (5). 
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(2) A detailed description of the resources used 
by home health agencies, physicians, and the De-
partment of Health and Human Services and its 
contractors in conducting such pre-claim review. 
(3) A description of alternative measures that 
can be taken to identify the nature of improper pay-
ments in Medicare home health services, the root 
cause for such improper payments, and possible cor-
rective actions (other than the use of pre-claim re-
view) that can be taken. 
(4) Detailed data on the claims subject to, and 
the result of, Medicare pre-claim review conducted 
before the date of the enactment of this Act, includ-
ing the following: 
(A) The number of pre-claim submissions 
and resubmissions. 
(B) The percentage of responses to such 
submissions and resubmissions that— 
(i) fully approve (or affirm) such serv-
ices; 
(ii) fully disapprove (or non-affirm) 
such services; or 
(iii) do not fully approve (or affirm), 
or fully disapprove (or non-affirm), such 
services. 
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(C) Changes in utilization of and spending 
on Medicare-covered home health services, inpa-
tient hospital care, and skilled nursing facility 
services. 
(D) The number of home health agencies 
in States where such pre-claim review occurred. 
(E) The average dollar amount per claim 
and aggregate amount involved in such reviews, 
based on the types of responses described in 
subparagraph (B). 
(F) The 50 diagnosis codes that were most 
frequently subject to review. 
(G) The proportion of cases subject to re-
view that were post-acute care. 
(H) The impact of the review on patient 
access to home health services. 
(I) The impact of the review on the con-
tinuity of care, including the proportion of cases 
that result in a disruption or delay in patient 
care. 
Æ 
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