CMS has implemented a new requirement, Pre-Claim Review (“PCR”). This new rule has been imposed in a whirl-wind “demonstration” project. Initial guidelines were issued on June 8th and the program was adopted and implemented less than two months later, effective August 1st, 2016 for Illinois for patients with a SOC after that date. Illinois is the first of five states subject to the program, which will grow to include Florida, Texas, Michigan and Massachusetts.
The project was explicitly announced as an initiative to reduce fraud. The essence of the pilot is a new process that requires Home Health Agencies (HHAs) to submit documentation relating to a claim earlier than was previously required. This allows CMS the ability to review documentation to ensure sufficient probability of payment of a claim earlier in the episode.
Home Health Agencies will be submitting the same documentation as has always been the case. However, it must now be submitted within the first 30 days of the episode for the PCR. A claim which preliminarily meets the criteria established for payment of a claim will receive an “Affirmation,” meaning that CMS is likely to approve the claim. If CMS determines that the documentation is not sufficient to meet approval criteria, the claim may receive a “Non-affirmation,” which means CMS is likely to deny the claim. The agency may then submit additional documentation, and do so as many times as necessary.
The qualifications for approval remain the same as in the past: the individual must:
For agencies, areas of particular importance will be:
Additional implication for HHAs include:
The implication for clinicians include:
Once gathering the initial documentation has been completed, the HHA must submit the information for the Pre-Claim Review within 30 days of the start of the episode. The CMS Medicare Administrative Contractor (“MAC” - such as Palmetto) will return a finding within 10 days of submission. Each PCR claim also receives a UTN (“Unique Tracking Number”) which follows the claim. A copy of the decision is also sent to the patient.
If the agency does not submit a claim to PCR, it may still be paid upon final submission, but the amount will be reduced by 25%. Thus, while “voluntary”, the implementation of PCR is likely to be virtually universal.
Because CMS will be sending notice of its determination of Affirmation or Non-affirmation to both the agency and patient, patients are likely to ask more questions about the process and their rights and responsibilities. Patients that receive a Non-affirmation finding are likely to want to know what and how they can proceed. Patients have a right to assemble additional information and submit it directly to the MAC just as agencies can. It is highly recommended that they work in concert with their HHA to do so. Only one agency may have a valid UTN at a time, so if a patient changes agency, the case will need to be resubmitted by the new agency.
From a practical standpoint, the PCR process has relatively little impact on clinician’s day to day activities, perhaps with the exception of increased focus on timeliness and quality of notes. Clinicians with strong work habits should be fine in continuing their daily work. That said, the process will have a big impact on HHAs from a documentation timing and administrative follow-up stand-point. Understanding and adapting to these new processes are likely to cause agencies to take additional time and admit fewer patients. This in turn can impact the patient load and opportunity for clinicians.
Aptiva has positioned itself as the premier provider of quality services in the market. We are extremely proud of the quality of the clinical care and documentation that we provide, through you, our expert clinicians. While this may represent a short-term challenge for Aptiva and all HHAs as they adapt to new standards, we believe that in the long-run, it will help us succeed as agencies move toward quality over deeply discounted providers. We ask all of you to stay focused on providing great care, thorough documentation, and ensuring that our patients have the best possible outcomes. While this transition may be a difficult period, we believe that quality, high-value service will ultimately prevail, and our clinicians will enjoy an even greater level of success.