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:
- 2013 - 17.3% Error Rate
- 2014 – 51.4% Error Rate
- 2015 – 59% Error Rate
The Pre-Claim Review Demonstration Process:
The demonstration will be phased in over a 6 month period for the states in the following order:
- Illinois – August 1, 2016
- Florida – October 1, 2016
- Texas – December 1, 2016
- Michigan and Massachusetts – January 1, 2017
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 submits initial RAP and current RAP process will not change.
- After submission of RAP and prior to submission of final claim the Pre-Claim documentation is submitted to MAC.
- The following items were identified as being required for a Pre-Claim submission:
- Physician demographics and NPI number
- Agency demographics and NPI number
- Benefit Period
- Dates for claim (SOC date to End Date)
- Initial (admission) or Recertification Period
- Documentation to support medical necessity/homebound status
- Face to Face Encounter
- Plan of Care/485
- OASIS/visit documentation
- The submission can be completed by mail, fax or electronic submission.
- The MAC has 10 days to respond to the first submission for Pre-Claim Review.
- The MAC will either affirm that the documentation supports the requirements OR not affirm that it meets the requirements.
- Affirmed episodes will be given a unique tracking number that will need to be included on the final claim.
- Non affirmed episodes – the agency will have the opportunity to gather additional information and resubmit the documentation MAC for affirmation.
- The MAC has 20 days to respond to resubmission of documentation.
- There is no limit to the number of times an agency can resubmit information to the MAC for approval.
- Agencies can submit final claims without an affirmed Pre-Claim number.
- Final claims without an affirmed Pre-Claim number will be subjected to a 25% reduction in the reimbursement automatically.
- The claim then will be reviewed and if the documentation does not meet the requirement, the appeal process related to the claim can be enacted.
- The 25% reduction will not be part of the appeal process and will be in place for all cases not getting a Pre-Claim affirmed.
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.