Home Health & Hospice Week

PCR demo launches in initial state.

As the Aug. 1 launch date for the pre-claim review demonstration neared, CMS and its contractors continued to issue instructions and clarifications to the home health agencies about to go under the 100 percent claim review system.

For example: Nervous Illinois agencies trying to test out Palmetto GBA’s eServices system for the program were shut down by the HHH Medicare Administrative Contractor. In a July 26 email, Palmetto instructed agencies to “refrain from submitting TEST requests and only submit valid requests to Palmetto GBA for consideration.”

Why? “Palmetto GBA began accepting Home Health Pre Claim Review submittal requests on July 15, 2016,” the MAC explained. “Our eServices submittal request is live and does not have functionality available for providers to send in test submissions. Some providers have submitted TEST Home Health Pre Claim Review requests through eServices which are not able to be processed.”

Meanwhile: Palmetto will be handling the vast majority of PCR claims for Illinois, but some agencies under the demo will submit their claims to CGS. The MAC renamed and updated its demo website at www.cgsmedicare.com/hhh/medreview/pre_ claim_review_demo.html. It includes step-by-step instructions for the program, as well as a link to the cover sheet it announced in a July 20 special Open Door Forum on PCR (see Eli’s HCW, Vol. XXV, No. 28).

And CMS put in writing the answer it gave in that forum, regarding demo agencies’ requirements for patients whose conditions change after receiving an affirmation decision. “If later in the episode the beneficiary’s condition supports additional services that were not on the initial provisionally affirmed pre-claim review request, you would not need to submit an additional pre-claim review request for that episode,” the agency confirms in its PCR frequently asked question set updated July 26.

However: In such scenarios, “CMS contractors (including Zone Program Integrity Contractors, Recovery Audit Contractors, and Medicare Administrative Contractors) may conduct targeted prepayment and post-payment reviews to ensure there is no evidence of fraud or gaming,” CMS warns in the FAQs.

Note: CMS’s PCR site is at www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Pre-Claim-Review-Initiatives/Overview.html. Access Palmetto’s PCR site at www.palmettogba.com — click on “Jurisdiction M Home Health and Hospice,” then click on “Home Health Pre-Claim Review” in the “Top Links” box.