Home Health & Hospice Week

Even agencies that qualify for exemption will be subject to 5% ‘spot check.’

One of the most pressing questions for the home health agencies scheduled to undergo the relaunched Pre-Claim Review demonstration first is how hard it will be to get quick relief from the program.

Unlike in the old PCR demo, the renamed Review Choice Demonstration sets out a way for HHAs to get off the heavy review track. Providers that choose the 100 percent pre-claim review or the 100 percent post-pay review (as opposed to taking the 25 percent penalty) “will continue to be subject to a review method until the HHA reaches the target affirmation or claim approval rate,” CMS explains in a supporting Paperwork Reduction Act filing.

That “approval rate” will be 90 percent, “based on a minimum of 10 pre-claim requests or claims submitted,” CMS spells out.

What happens next: “Once a HHA reaches the target pre-claim review affirmation or post-payment review claim approval rate, it may choose to be relieved from claim reviews, except for a spot check of 5 percent of their claims to ensure continued compliance,” CMS continues.

Alternative: “The HHA may also instead choose to continue or start participating in pre-claim review, or choose to participate in selective post-payment review based on a statistically valid random sample,” CMS adds in the PRA document.

While getting a specific number for exemption is good, CMS still has many questions left to answer about the exemption option. Agencies need “the specifics,” William Dombi, president of the National Association for Home Care & Hospice, tells Eli.

For example: “What does that mean for a large agency — only 10 or much more?” asks Sara Ratcliffe, executive director of the Illinois HomeCare & Hospice Council, of the “minimum of 10” language.

Plus: “We would like to know if Illinois agencies that had already achieved 90 percent affirmation or higher the first time around with PCR could be exempt this time,” Ratcliffe adds.