Medicare Compliance & Reimbursement

Take these pre-emptive measures to avoid furnishing free care.

Pre-claim review (PCR) is slowly ramping up in Illinois. Is your agency ready for the dawn of the 100 percent pre-pay review program?

Recap: After some Paperwork Reduction Act-related confusion, the Centers for Medicare & Medicaid Services (CMS) launched PCR in Illinois Aug. 3. Under the program, home health agencies (HHAs) submit a Request for Anticipated Payment (RAP), then a pre-claim review request including all documentation needed to support the claim (including the face-to-face physician visit note), and then the Home Health & Hospice Medicare Administrative Contractor will issue a decision on the request in a goal of 10 business days.

Here are 7 expert tips to help you gear up to meet Medicare documentation requirements and budget for hiccups once 100 percent pre-claim reviews go live:

1. Know the consequences. “Essentially, the pre-claim review process is akin to a ZPIC prepayment audit and has the potential to result in significant losses and additional costs,” emphasized clinical consultant Lista Clark with Healthcare Provider Solutions in Nashville, Tenn., in a June blog post.

2. Adjust your budget. “This requirement will take additional staff, time and costs to gather the required documentation timely and to track submissions, responses and needs for resubmissions,” Clark expected.

3. Plan for cash flow delays. CMS insists PCR will improve cash flow by giving agencies advance notice of claims problems. But since it amounts to a 100 percent prepay audit for all HHAs, you can expect cash flow slowdowns, believes attorney Robert Markette Jr. with Hall Render in Indianapolis. Resubmissions and appeals are likely to eat into your accounts receivable timeframes.

4. Whittle your turnaround time. The longer you furnish care without an affirmed PCR request, the longer you may be providing free care. “Review your process for obtaining all of the claims documentation required,” Markette urges. Try to get it under a week.

5. Implement immediate review. You’ll need to check physicians’ documentation as soon as it comes in the door to make sure it will pass muster under PCR review, and send it back for correction when needed, Markette counsels. The same goes for documentation from your own clinicians. Make sure you adjust your policies and procedures to reflect the new process, and get the process underway well before PCR requires it.

6. Educate docs and staff. Based on the problems you find in your internal documentation review, as well as non-affirmation reasons cited by MACs once PCR launches in your state, educate both physicians and your own staff on how to document to comply with Medicare requirements.

7. Consider grace period usage. For the first three months of the program in each state, CMS will process claims without a PCR decision without penalty (but still requiring medical review). After three months, the reimbursement rate will be reduced 25 percent for claims not undergoing PCR.

Agencies may want to consider “whether the three-month grace period is a time to ease into pre-payment review,” Markette suggests. “Submitting some, but not all, claims may provide a way to measure denial rates, turnaround times, etc. It may also help agencies to identify changes to documentation processes needed to ensure success once the three-month deadline has passed.”

Watch out: “Providers who consider this option need to be very careful to submit 100 percent of claims for pre-payment review before the grace period ends or they will lose 25 percent of the claims that were not submitted,” Markette cautions.

Note: CMS’s PCR website is at www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Pre-Claim-Review-Initiatives/Overview.html.