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Pre-Claim Review Demonstration for Home Health Services



The Centers for Medicare & Medicaid Services (CMS) is implementing a three-year Medicare pre-claim review demonstration for home health services in the states of Illinois, Florida, and Texas beginning in 2016, and in the states of Michigan and Massachusetts beginning in 2017. CMS is testing whether pre-claim review improves methods for the identification, investigation, and prosecution of Medicare fraud occurring among Home Health Agencies (HHAs) providing services to people with Medicare benefits. Additionally, CMS is also testing whether the demonstration helps reduce expenditures while maintaining or improving the quality of care.


What does this mean for me?

In 2015, home health claims had a 59 percent improper payment rate, and a large proportion of the improper payment rate was because of insufficient documentation. The pre-claim review demonstration will help educate HHAs on what documentation is required and encourage them to submit the correct documentation, while still allowing the HHA to begin providing services and receive initial payments prior to the pre-claim review decision. The demonstration also aligns Medicare’s payment requirements and approach with commercial insurers, including some Medicare Advantage plans.


What should I do today to be ready for this?

When is the last time your organization conducted an internal review of its coding and billing practices? If your answer is more than one year, your organization may be at risk. As we all know, the healthcare industry is a highly regulated arena with a framework that includes a variety of progressive administrative sanctions that may range from monetary penalties to exclusions from federal and state healthcare programs on up to incarceration. Any imposed regulatory sanction will affect all levels of the healthcare organization. Effects will be felt from the individual providing direct healthcare, to the person performing the coding or billing function, to the organization's governing body.

I don’t understand what the difference is between pre-claim review and prior authorization?


What is pre-claim review?

Pre-claim review is a process through which a request for provisional affirmation of coverage is submitted for review before a final claim is submitted for payment. Pre-claim review helps make sure that applicable coverage, payment, and coding rules are met before the final claim is submitted.


How is pre-claim review different than prior authorization?

A pre-claim review is different than a prior authorization due to the timing of the review and when services may begin. For prior authorization, a request must be submitted prior to services beginning and providers should wait until they have a decision before they begin providing services. With a pre-claim review, services have already begun and the request is submitted after all of the initial assessments and intake procedures are completed and services have begun. The pre-claim review occurs after services start but prior to the final claim being submitted.


Is pre-claim review needed for beneficiaries in the states already receiving home health services before the demonstration's start dates?

Home health services provided to beneficiaries after the start date of the demonstration in their state will be subject to pre-claim review.


Ask how Netsource One can help with your preparations before you ring Happy New Year of 2017 with pre-claim reviews by CMS.