Pre-Claim Review Postponement


The Centers for Medicare and Medicaid Services (CMS) announced the postponement of the start dates for the subsequent pre-claim review (PCR) demonstration states – Florida, Texas, Michigan, and Massachusetts.

CMS announced the change after the experience in Illinois has highlighted the need for additional education efforts prior to further expansion to other states.

According to CMS, the “education effort will focus on how to submit pre-claim review requests, documentation requirements, and common reasons for non-affirmation.” Pre-claim review (PCR) demonstration project was introduced to improve the “identification, investigation, and prosecution of Medicare fraud occurring among Home Health Agencies (HHAs).  In addition, CMS is also testing whether the demonstration “helps reduce expenditures while maintaining or improving quality of care”.

The PCR demonstration requires HHAs to submit appropriate administrative and clinical documentation to receive provisional confirmation of eligibility for coverage prior to the submission of a final claim for an episode.  Although stated as not mandatory, if this pre-claim approval is not received, the final episode payment is subject to a 25% penalty deduction. Essentially Medicare certified HHAs are submitting the same information required for final payment, but earlier in the care process, and lead to an increased administrative overhead.

When the PCR demonstration project was announced, Illinois was scheduled to start August 1, with Florida no earlier than October 1, 2016; Texas no earlier than December 1, 2016; and Michigan and Massachusetts no earlier than January 1, 2017.  However, PCR was implemented in Illinois on August 3rd after a 2-day administrative procedural delay.

This newly announced postponement suspends previously announced start dates, and CMS has indicated they will not continue the PCR demonstration in other states without at least providing a 30 days’ notice on this website. CMS also states this is only a temporary pause, in spite of intense lobbying to members of Congress by individual agencies, NAHC and state home health associations.

Given the additional time for preparation, Medicare certified HHAs should begin streamlining processes and receiving the appropriate documentation from referral sources in a timely manner, while focusing on the referral order, certifying documentation and face to face encounter. The technology partner of HHAs are crucial, decreasing the administrative burden of PCR and providing a platform for tracking, reporting, monitoring claims data and reimbursements, while ultimately supporting your agency’s growth.

 

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