Questions on Pre-Claim Review?

Author: tbryan

We're less than a week away from the anticipated launch of pre-claim review in Illinois. If you're in one of the five states that will be participating in pre-claim review before 2017, you're probably looking for answers to a lot of questions.

There is a lot of information we do have on the pilot, but agencies still have a lot of questions. Even after several open forum calls with CMS. So what are the most important things that we don't know yet?

  • What specific documentation will be required?

CMS has stated on their FAQ "pre-claim review does not create new documentation requirements." Many agencies have compared the process to an Additional Documentation Request. But because proving medical necessity can be entirely subjective, agencies are still left with the puzzle of delivering what each reviewer will need to see to prove homebound status and necessity. Which brings up the next question:

  • Who will be reviewing the documentation? And (how) will they be trained?

The MACs have stated on the open forum calls that they have enough staff to handle the reviewing of documentation, and that the reviewers will primarily be nurses. A nursing perspective will help, but if there are no guidelines determined by CMS for approval of pre-claim reviews, documentation requirements are a moving target.

  • How much is this going to cost for agencies?

Even with no new documentation requirements, there's going to be an administrative burden on agencies to process this paperwork. Software can help ease this burden significantly, but every new regulation means more time and paperwork for agencies€”and sometimes may even require new employees.

  • Ultimately, how is this going to affect my patients?

We know most agencies get into home healthcare because they want to take care of people. A lot of agencies view new regulations as burdens that take them away from their passion. The pilot is designed to aid in the delivery of proper care, reducing fraud and freeing compliant agencies to deliver quality care to patients who need it.

If your agency is asking any of these questions, you are certainly not alone. The important thing is that we remember this is a pilot. This is designed to test the system for future improvements. CMS and the MACs will be rolling out more information until the pilot launches, and as they learn more information through the pilot.

We'll continually update our blog with the latest information to make sure you're ready for pre-claim review, whether you are immediately affected or if you'll be rolled into the program later.