Healthcare Provider Solutions

CMS released a Comment Request, via the Federal Register, regarding Pre-Claim Review Demonstration being set to return on or after October 2018 in Illinois, Ohio, North Carolina, Florida, and Texas.

For a review of the structure of Pre-Claim Review please click here.

As the excerpt from the comment request states below, agencies will be able to choose whether pre or post-pay review and or not at all with an agency not participating receiving a 25% reduction in payment and being subject to Recovery Audit scrutiny.

“CMS proposes to offer choices for providers to demonstrate their compliance with CMS’ home health policies. Providers in the demonstration states may participate in either 100 percent pre-claim review or 100 percent post-payment review. These providers will continue to be subject to a review method until the HHA reaches the target affirmation or claim approval rate. 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 their claims to ensure continued compliance. Providers who do not wish to participate in either 100 percent pre-claim or post-payment reviews have the option to furnish home health services and submit the associated claim for payment without undergoing such reviews; however, they will receive a 25 percent payment reduction on all claims submitted for home health services and may be eligible for review by the Recovery Audit Contractors.”

A Frequently Answered Questions (FAQ) document was released on May 31.

The FAQ clarifies that the revised demonstration would last five years and that Illinois will kick off the demonstration again and will be followed by Ohio and North Carolina and later Texas and Florida.

Agencies need to submit comments. We not only need a volume of comments, but we need quality comments that express how unreasonable this situation is, especially when some of the demonstration states are already under Value-Based Purchasing and all of the demonstration states have Targeted Probe and Educate occurring on multiple agencies. Comments do not need to be lengthy, but they need to discuss the seriousness of this situation and how it will negatively impact your agency and patient care.

The comments are due July 30, 2018 and can be submitted here.