What You Need to Know About the Possible Pre-Claim Review Process

If you have not heard yet, The Center for Medicare & Medicaid Services (CMS) is considering bringing back the pre-claim review process for Medicare claims in home health care that had been previously paused in 2017. This program has been controversial in the past, but it has also been recognized as something that is necessary for most. They are leaving it up to you to decide if you feel like you need it and we want to give you all of the information to help you make that decision.

Here Is The Scoop

The Initial Program. CMS originally released the Paperwork Reduction Act of 1995 in order to “require agencies to plan for the development of new collections of information and the extension of ongoing collections well in advance of sending proposals to OMB”. This act requested that you “seek public comment on proposed collection of information through 60-day notices” and that OMB has acknowledged the situation enough to possibly “reduce the burden of collection on small businesses, local government and other small entities.” The industry did not respond well to it, claiming that it was a burden to them and ‘poorly administered.’
The New Revisions. The program was postponed indefinitely, but on April 1, 2017, CMS opened up the new considerations to the providers. It appears that, now, home health agencies will have three options:

  1. Pre-claim review
  2. Post-payment review
  3. Minimal post-payment review with a 25% payment reduction for all services through home health in the demonstration states

If you choose to select one of the first two options, a review will be required for each part of the care you provide.
The Purpose It Serves. The whole point of implementing these services is to better organize the investigations surrounding Medicare fraud. With these steps in place, it will be easier for CMS to navigate exactly the type of care that is being provided and if they are able to cover it.
Who Does This Affect? The act will begin with a collection of states they deem to have more frequent occurrences of “fraudulent behavior.” These states include:

  • Illinois
  • Ohio
  • North Carolina
  • Texas
  • and Florida

What A Pre-Claim Review Consists Of. In a nutshell, you will be required to request the necessary coverage from Medicare in order to determine whether or not your patients’ circumstances apply. This review may take place after you have provided all services, it simply is meant to ensure that the payment and coverage are possible before the final claim is submitted.
How Does It Differ From Prior Authorization? Pre-claim review is not the same as prior authorization. Prior authorization is where a request must be submitted before services begin; requiring providers to wait until they receive the green light to ensure that their care is clear for coverage. The difference between the two is that, with pre-claim reviews, services can begin before clearance.

The Final Details

The earliest this demonstration is expected to take place will be the 1st of October in 2018. CMS is still navigating the terms and the general response from home health care providers. As they explore the most efficient way to approach these reviews they will continue to keep the public informed over the months to come. The intention is to make the whole process easier and align with the needs of providers like you.
Here at Precision Medical Billing, we make it our priority to stay current on the latest news impacting medical billing. Follow our blog so that you can stay in the loop, too. For more information on medical billing for home health, please contact us here.