What the Possible Return of Pre-Claim Review Demonstration Means for Home Health Care Agencies

Despite objections from stakeholders in the home health industry, the Centers for Medicare and Medicaid Services (CMS) is considering bringing back the Pre-Claim Review Demonstration (PCR) initiative. Initially rolled out in Illinois in August 2016, CMS revoked its plans to extend to program to other states due to negative feedback from those involved in home health services. Now, CMS wants to reintroduce the initiative, but with some key changes.

What is the Pre-Claim Review Demonstration for Home Health Services?

The overall purpose of the initial PCR was to test whether a pre-claim review process would help to better identify and prosecute Medicare fraud among HHAs. In its initial form in 2016, the program required HHAs to submit documentation for Medicare reimbursement claims before receiving payment from CMS. The claim-supporting documentation for PCR was the same as the documentation required for standard post-claim audits, just submitted earlier in the process. Medicare would review the submitted documents, and either approve the claim or request additional supporting documentation from the HHA (or other payment beneficiary). If a home health agency opted out of submitting documentation for pre-claim review, they would incur a 25% penalty on the payment received.

PCR was to replace the previous model in which CMS would make payments first, and then retroactively have to “chase down” those who were found to have submitted fraudulent claims. Many improper payments among HHAs were found to be due to improper documentation, so in theory it makes sense that requiring a review of claims before distributing payment would simplify the process and reduce rates of mispayment. This would help free up CMS resources that were being spent on laborious fraud investigations and tracking down those who committed fraud.

Why Was the PCR Program Initially Suspended?

The 2016 roll out of the PCR initiative did not have a positive response from those in the home health industry. Because of the program requirements, CMS received significantly more claim reviews than in the past, resulting in administrators losing documentation and incorrectly denying claims, among other problems. Some providers even reported resubmitting incorrectly denied claims without making any changes, and having the claim approved upon resubmission. The program that CMS introduced in Illinois in 2016 was confusing, and ended up requiring significant time and energy from providers and HHA administrators- time that could have been spent focusing on patients. The messy roll out did not give the home health industry confidence that the PCR program would have a positive impact, and rather made it seem like a waste of time for providers.

Another one of the big concerns about the initiative was that it would force HHAs to postpone patient care while waiting for CMS approval, and thus reduce patients’ access to care. The program could also lead to additional financial burden on patients and providers. Overall, the original PCR was very burdensome for providers in Illinois, and providers in the rest of the country feared that its further implementation would end up hurting patients.

The Return of the Pre-Claim Review Demonstration: What is Different?

CMS recently announced that they are planning to introduce a revised version of the PCR program. Once again, Illinois will be the first state targeted. The updated program is designed to give providers more choice and flexibility with submitting their claims and reward providers who demonstrate compliance with CMS home health policies. Under the new plan, providers have three choices of how to go about their claim review. HHAs may choose to undergo either pre-claim review or post-payment review. Providers may also choose to skip out on either options and instead simply face “minimal post-payment review.” However, the latter option will result in a 25% payment reduction. Like in the original version of the initiative, PCR does not require any additional documentation than what is standard for claim review.

Once providers reach targeted affirmation rates, or rates of claim approval, they can opt-out of claim reviews other than occasional checks to ensure that they are continuing to comply with Medicare guidelines.

What the Return of PCR Means for You

The return of PCR is especially important for HHAs in the state of Illinois, which will be the first state to pilot the revised version of the program. Ohio, North Carolina, Texas, and Florida are slated to follow. Still, even HHAs in Illinois have at least a few months to prepare themselves- CMS announced that the new program will be implemented no earlier than October 1, 2018. One thing home health providers or stakeholders can do is provide comment on the revised plan. CMS set up an online form for the public to submit their comments and concerns about the return of the program. For many in the HHA industry, this is a step in the right direction compared to the original PCR implementation, which was rolled out without any opportunity for public comment.

Although some members of the HHA community are pushing back against the proposed reintroduction of the program, providers still need to prepare themselves, especially in Illinois. One way for HHAs in Illinois to prepare is to get in touch with a consulting firm with experience from the first round of PCR. These professionals can help guide your HHA through the implementation process so you do not get overwhelmed by the administrative aspect of PCR and can focus on patient care.

Almost everyone can agree that CMS’ intentions with PCR are good- reducing Medicare fraud ultimately saves taxpayer dollars and frees up valuable CMS resources. But, if the first implementation of PCR is any indication, it may be a bumpy road to get the program to a point where it benefits the HHA community rather than complicate it. To ease the transition and get a better hold of PCR, contact Liberty Consulting.

Add Your Comment