What the Pre-Claim Review Demonstration Means For Your Agency

Author: tbryan

The Centers for Medicare and Medicaid Services (CMS) recently introduced the Pre-Claim Review Demonstration in states identified as having higher rates of fraud, abuse, and over-spending. This is in addition to home health agencies being bombarded with new regulations almost monthly. We see this focus highlighted in multiple items of regulatory law including:

- Moratoria of new home health agencies and sub-units in Ft. Lauderdale, FL; Detroit, MI; Dallas, TX; Houston, TX; and Chicago, IL
- Home Health Value Based Purchasing Model (HHVBP) in the states of Washington, Arizona, Nebraska, Iowa, Tennessee, North Carolina, Massachusetts, Maryland and Florida
- Proposed Rule published July 5, 2016
- PECOS and Provider enrollment mandates
- Face to Face encounter and Certification/Recertification regulation refinement and enforcement
- Proposed updates to Conditions of Participation

The Pre-Claim Review Demonstration will affect all Medicare certified home health agencies in the states of Illinois, Florida, Texas, Michigan and Massachusetts and has the potential to greatly impact cash flow. Agencies will need to closely look at their processes, work flow, and compliance timelines in order to ensure that cash flow is not adversely impacted during the next three years.

The Pre-Claim Review Demonstration seeks to ensure that Medicare funded home health services are paid for only when the beneficiary meets the criteria for service coverage, and when the services are considered reasonable and necessary according to Medicare's Benefit Policy Manual guidelines. Agencies in the demonstration states have a history of showing evidence of fraud and abuse, and the majority of the pre-claim review states are included in the moratoria states as well. For this reason, the demonstration is being implemented as a means of reducing improper payments before the final claim is paid. Currently, CMS has to "pay and chase" improper payments through Additional Documentation Requests (ADRs), Zone Program Integrity Contractor (ZPIC) and Recovery Audit Contractor (RAC) review processes, which have proven to take years to recoup inappropriate payments.

In the new demonstration, Medicare certified agencies will be required to submit a per-episode request for provisional affirmation of coverage before final claims are submitted for payment or will receive a 25% payment penalty for non-compliance with this request requirement. This requirement will begin no earlier than:

- August 1, 2016 in Illinois
- October 1, 2016 in Florida
- December 1, 2016 in Texas
- January 1, 2017 in Michigan and Massachusetts

While the pre-claim review does not require any new documentation requirements, it does require that agencies streamline their processes in the following areas:

1. Receipt of documentation from the referring provider or facility
2. Receipt of certification documentation from the provider who establishes and periodically reviews the plan of care
3. Documentation of the actual face to face encounter as required
4. Timeliness of agency clinician documentation
5. Signature of physician orders

This documentation will all need to be submitted to the agency's Medicare Administrative Contractor (MAC) with the pre-claim review request. The MAC has 10 business days, after submission by the agency, to review and make a decision in the affirmative or negative as to whether the requirements for Medicare funded home health care have been met. If the MAC finds the documentation does not support requirements, the agency can amend and re-submit for another review, and continue to do so until the documentation passes. Once the agency receives an affirmative review notice, they can then submit the final claim for full payment.

Each Pre-Claim Review request will have an associated tracking number that will have to be placed on the final claim in order to process the final. The good news is that final claims that have a provisional affirmation pre-claim review decision will not be subject to additional pre or post-payment review or ADR. However, CMS contractors including ZPICs and MACs MAY conduct targeted pre- and post-payment reviews to ensure that claims are accompanied by documentation not required or available during the pre-claim review process. An example of this would be an ADR for review of reasonable and necessary skilled services on clinical notes, timeliness of physician signature on orders and other Medicare requirements as noted in the State Operation Manual, Chapter 7 of Publication 100-2.

The pre-claim review request may be submitted any time before the final claim is submitted, and as soon as all the required documentation from the medical record supporting medical necessity and eligibility requirements are met are obtained by the home health agency. Agencies are expected to provide services to the beneficiary in the meantime so as not to delay provider-ordered, medically necessary, skilled care. Again, this means that agencies must focus on their referral and recertification processes, including possible education of referral sources and physicians. Because the regulations have not changed in any way due to this demonstration, it is assumed that agencies have already established and are complying with regulatory processes and have been communicating with referral sources regarding regulation and needs. CMS has also been providing resources for training physicians on home health requirements and regulation compliance.

Agencies will need to bear in mind that the pre-claim review process does NOT negate other timelines and requirements such as auto cancellation of Request for Anticipated Payment (RAPs), or suspension of RAP privileges for high RAP auto-cancellations, for example.

While new and ever-changing regulation is often challenging, we know in Medicare-funded home health care, it is inevitable but also provides opportunities such as improving agency operations. Agencies have a vast library of training resources available to them through CMS' website, their MAC's website, and Axxess' website.

Having a designated person, or team of persons, in each agency whose focus is regulatory compliance and training is best practice and has a well-documented return on investment. A well-functioning QAPI committee is also a must in the modern home health environment, in order to ensure quality of services which are now being tied to payment in the HHVBP model, and will continue to be tied to payment in the future.

For agencies not included in the pre-claim review demonstration, focusing on the required documentation (minus the pre-claim review request, of course) and streamlining these processes means that you can bill earlier, and that charts will be audit-proof upon ADR or other review, even if it comes months or years after payment is received.

For more information on Pre-Claim Review, HHVBP, and other changes, stay tuned to Axxess' website as we will continue to publish free, on-demand webinar content as well as blogs and white papers. Our website can be found at www.axxess.com/on_demand.

For more information on the Pre-Claim Review, visit the Palmetto GBA website here:

As I often like to say "There is plenty to think about, but nothing to worry about." Make a compliance plan, implement the plan, review the plan, and adjust as needed. This is how home health agencies have absorbed change and continued to excel again and again. Axxess is here to help you succeed. Together we can do great things and ensure our patients continue to receive the care they deserve and need.