Pre-Claim Review Demonstration
Pre-Claim Review Begins in Five States: August 1st is the First Date, Illinois is the First State
Effective August 1, 2016, Home Health Agencies in five states will begin the three year Medicare pre-claim review demonstration by which an agency will complete the patient assessment, initiate procedures, and establish services then submit a request via fax, mail, or electronic submission of medical documentation to the respective MAC for approval prior to the submission of the final claim. The MAC is expected to provisionally approve or disapprove the services within 10 business days. If the MAC denies the payment, the agency can resubmit a new request
What is the Difference between Pre-Claim and Prior Authorization?
Per CMS, with a Pre-Claim review, services have already begun and the request is submitted after assessments and services have been completed or begun. Prior Authorization requires a request prior to services being initiated. CMS states this new requirement is not creating new documentation requirements. The agencies are to submit the same information they currently submit for payment, but do it earlier in the process.
What States are Included in the Demonstration?
The demonstration will begin no earlier than August 1, 2016 in Illinois, no earlier than October 1, 2016 in Florida, and no earlier than December 1, 2016 in Texas. The demonstration will begin in Michigan and Massachusetts no earlier than January 1, 2017. (Pre-Claim Demonstration for HH FAQ, 6/8/2016)
The demonstration is expected to have minimal effect on beneficiaries per CMS. The Pre-Claim request is submitted after a RAP but before the submission of the final claim. However, some agencies have expressed concern, stating that in an already fragile bottom line market, any further delay of payment could be harmful to the agency’s financial health.
CMS states the five states chosen “show extensive evidence of fraud and abuse in the Medicare home health benefit for treatment performed in these states” (CMS Pre-Claim Demonstration for HH, FAQ, 6/8/2016).
Decision, Documents Needed, and Options
For pre-claim review, the MAC will make the determination using regulation, National Coverage Determination, and Local Coverage Determination requirements. The MACs will be expected to respond within 10 business days for an initial request and 20 business days for a resubmitted request following a denial.
Resubmissions may be sent an unlimited number of times as necessary, but obviously, the agency will want to get the appropriate information submitted up front to minimize payment delays. There will be a tracking number on each decision notice and that number will be used on the claim.
CMS states that, generally those claims that had the provisional review will not have additional review. However, note that Z-PICs conduct targeted prepayment and post payment review which will continue and CERTS review a stratified random sample of claims annually to identify improper payments. That CERT sample may include the pre-claim reviewed items also.
If an agency would be denied payment and after resubmission still receives denial, they could follow the appeal process. If an agency submits a claim without a pre-claim review, per CMS, if that claim is deemed payable, it will be paid at a 25% reduction of the full claim benefit. Obviously, an agency would have serious financial if that became the agency process.