CMS held a special open door forum on June 14, 2016 releasing initial information on the new Pre-Claim Review Demonstration for Home Health Agencies. According to CMS this demonstration is the latest effort to prevent fraud and abuse in the home health industry.   The following states were chosen to be in the demonstration: Illinois, Florida, Texas, Michigan and Massachusetts.   According to CMS, these states were chosen based on their higher than average rate of improper Medicare billing. CMS identified that the Medicare error rate has steadily risen since 2013 as identified in CERT reviews. The CERT Error Rate history includes:

The Pre-Claim Review Demonstration Process:

The demonstration will be phased in over a 6 month period for the states in the following order:

The focus of the Pre-Claim review is to affirm that the episode meets the documentation requirements for certification for home health services. Each MAC is responsible for developing their own form/process for submission of the Pre-Claim. The general workflow as outlined in the CMS Open Door Forum call is as follows:

Agency Implementation Plan:

The Pre-Claim review process will require agencies to increase their scrutiny of documentation prior to submitting the final claim.   Agencies should start now with assessing their internal process for obtaining face to face documentation and plan of care/485 orders.   Face to Face documentation must identify the patient’s homebound status and skilled need for home health services.   The actual physician or physician extender face to face visit encounter documentation must also be submitted.   Agencies should include any other documentation that would support the medical necessity or homebound status. Items such as hospital notes, rehabilitation therapy notes or history and physicals should be submitted.

Agencies should assess their clinical documentation to ensure it includes specific reasons for homebound status. Stating that patient is homebound due to requiring a taxing effort to leave the home and requires assistance, is not enough justification to meet the homebound requirements. The homebound reason should be individualized to the patient and include specific reasons why the patient has a taxing effort to leave the home.   Consider including assessment details, for example: shortness of breath after xxx amount of feet or inability to ambulate greater than xxx feet due to muscle weakness in lower extremities due to fracture of right leg.  

The documentation should paint a picture for the reviewer of the patient condition and events that led up to the admission.   Include in a narrative note the current status of the patient and the reason why the patient now requires home health services.   Include any extenuating circumstances such as caregiver availability and willingness/ability to provide support, the layout of the home i.e. are there steps that must be negotiated to enter/leave the home, issues with the home environment from a safety perspective, and identify any comorbities that will impact the need for home health services. Clearly identify the services ordered or evaluations required and include the reason for these additional services.

CMS stated that the Pre-Claim Review will reduce the number of ADR and Claim denials that agencies are currently facing. While this may be true it will require agencies to have additional processes in place to track the Pre-Claim Reviews submission, tracking those submissions for affirmation, resubmitting documentation as necessary, tracking the resubmissions for affirmation and then including that unique identifier number on the final claim.   And let’s not forget that agencies still have all the other items in their current claim process to complete before that final claim is submitted.

By Diane Link, Senior Clinical Consultant, BlackTree Healthcare Consulting on Thursday, August 18, 2016