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What the CMS Pre-Claim Review Demonstration Means for your Home Health Agency

Posted by John Blake on February 24, 2017
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Home health agencies serving Medicare and Medicaid beneficiaries are up in arms (and rightly so) with the Centers for Medicare and Medicaid Services Pre-Claim Review Demonstration that is now underway after a delayed start. With Illinois, Florida, Texas, Massachusetts, and Michigan slated for the pilot program, many worry how they will withstand a program that mandates them to submit to a pre-claim review process. Weeding out fraud, abuse and improper payments are at the root of this program, but many fear that they are being penalized unfairly.

What the Numbers Show: Illinois Pre-Claim Affirmations

Given the delayed start to the Pre-Claim Review Demonstration, limited data is available, with just the results from Illinois available at this time. Initial reports are favorable, with the CMS reporting that “91.7 percent of pre-claim review requests in Illinois received provisional affirmation, including both fully affirmed or partially affirmed decisions.” So what does this mean? With affirmations above 90%, it appears that the majority of Medicare beneficiary pre-claims submitted were indeed compliant with the Medicare requirements and are eligible for payment. With such a high compliancy rating, is it necessary to undergo pre-claim reviews?

While these figures demonstrate that the Medicare requirements are being applied appropriately by the majority of home health agencies in Illinois and are not subject to fraud, abuse or improper payments, these extra steps are having negative effects in the way of delaying care and payment to home health agencies.

3 Tips to Safeguard Your Home Health Business During the Pre-Claim Review Process:

  1. Ensure all documentation is complete, including obtaining a physician’s signature to avoid delays or non-affirmation of your pre-claim.
  2. Be proactive: Educate the Medicare beneficiaries under your care regarding the Pre-Claim Review Process so that they are not blindsided by a letter from CMS should their pre-claim not be affirmed, and they understand why their care may be delayed.
  3. Consider diversifying your payer sources to avoid cash flow disruption: Pre-claim review will delay your payment.

What to Expect from the Pre-Claim Review Demonstration Process:

You must submit pre-claim reviews for all Medicare services and they must be affirmed in order for you to receive payment. Should your pre-claim be denied, you have the right to seek an appeal. If your claim fails to be affirmed and you are unsuccessful in the appeals process, a letter will be sent out to the Medicare beneficiary alerting them that they are not covered for the Medicare services you are providing to them.

Patient care continues to be the top priority for home health agencies navigating the pre-claim review process. Maintaining open lines of communication with patients and staff regarding the process is important. Working to educate your staff is critical to ensure that your agency is compliant with the pre-claim review process.

For more information on the CMS Home Health Care Pre-Claim Review, and to stay up to date with pre-claim affirmation statistics, see:

Topics: Home Health, Home Care, Medicare

John Blake

Written by John Blake

John Blake, Director of Client Success with PlayMaker, has dedicated his work efforts to the Customer Relationship Management industry for more than 20 years. His blended knowledge of CRM best practices along with post-acute care sales and marketing ensures that every client becomes a reference.