Home Health & Hospice Week

There is one big difference.

What’s the difference between the new preclaim review request demonstration and prepayment medical review? Not much, it turns out.

“This sounds like a 100 percent probe audit,” one home health agency representative told the Centers for Medicare & Medicaid Services in its June 14 special Open Door Forum on the demo. The demo will be looking at every single patient, the rep pointed out.

“You’re right,” a CMS official replied. “But there’s one big difference,” she pointed out. “That has to do with the appeals process.”

If you face a denial under prepayment review, your only option is to pursue an appeal through the very backlogged Medicare appeals system, which can take years. That is very expensive for the provider as well as Medicare, she noted.

Under the demo, you can submit the preclaim review request as many times as you want, giving you a chance to collect the documentation that’s missing and ultimately get your claim paid without resorting to the lengthy appeal process.

“We really believe … this [demo] will really help the home health agencies with cash flow,” said a CMS staffer in the forum. You will “know up front… you won’t have to wait until the end.”

Downside: However, all those resubmitted requests come at a price, experts remind agencies. Initial requests have a turnaround goal of 10 days for HHH Medicare Administrative Contractors, and resubmission requests have a 20-day timeline. That doesn’t include the extra time it takes the agency to analyze the results, gather new information (likely from reluctant physicians) and resubmit. Each new request can add up to a significant cash flow delay.

Result: This demo will be most effective at reducing the Medicare payment error rate for HHAs computed by the Comprehensive Error Rate Testing (CERT) program, which has embarrassed CMS for years, industry veterans observe.