Friday, July 29, 2016

Pre-Claim Review by CMS and its contractors is intended to change the face of Home Health

Originally published by kennedyhealthlaw.

CMS has announced changes to its claim processing for Illinois, Florida, Texas, Michigan and Massachusetts.  The Demonstration is called Pre-Claim Review.  It will change your world.  Pre-Claim Review (PCR) is scheduled to begin in Texas on or around December 1, 2016.  It is slated to last 3 years.

The Texas Association for Home Health and Hospice has called for its members (and anyone else who will) to call your congress person and insist that he/she stop the pre-claim review process because it will slow or cease home health patient access to care.

For those of you who have been subject to the recent ADR project, this is the ADR project on a long term extended release steroid.

CMS cites the increase in home health billing errors from the 17% percent in 2014 go over 51% in 2015.  Pre-Claim Review is not prior authorization, nor is it ADR or prepayment review.  The review of the paperwork comes before the HHA can submit the final claim and receive payment, and the review can come anytime after the client has been placed on service, even after the end of the episode.  Therefore, like an ADR for a final claim, you will have provided the services prior to getting approval for the submission of the final claim.  It is more a prior authorization for billing.  The permission given by CMS is to allow the HHA to submit its final claim.  Therefore it is not a pre-payment review, but a pre-submission review for permission to submit the final claim.  The claims will be paid as usual, but you can’t submit the final claim without the approval.

While the documentation requirements are not being changed for home health, you should be aware from your experience with the ADR project that claims are being denied for not having the appropriate paperwork anyway.  Home Health has always been highly regulated, and will now  be highly technical regarding the paperwork you must present.

If your agency submits paperwork that is not approved, your agency will have a couple of options, either correct and resubmit the paperwork (up to an unlimited number of times), or appeal the denial and go through the administrative process of Medicare.  Those of you who have been through the Medicare appeals process know how very long that can take.

CMS maintains that the no beneficiary will have his or her access to home health restricted in any way.  I expect that is correct at first.  If CMS and its contractors stall out of the gates as sometimes occurs when demonstration projects are kicked off, if provider’s submission permission for final claims are delayed very long (remember, this is not a delay in payment, but a permission vehicle for the HHA to submit its final claim) beneficiaries may have to change providers often, even though their access to care is not restricted.

There is still time for getting your agency shaped up prior to the beginning of the demonstration.

Curated by Texas Bar Today. Follow us on Twitter @texasbartoday.

from Texas Bar Today
via Abogado Aly Website

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