CMS recently announced the likely return of pre-claim reviews in Medicare home health. The return presents a new version of claim review that would give Home Health Agencies (HHAs) the option of 100% pre-claim review or 100% post-claim review. HHAs that achieve unstated performance levels would be exempted with only spot reviews to be used subsequently.
The demonstration project does not have a start date as of yet as it needs to go through the full approval process, which includes a 60 day period to allow for public comment.
According to CMS, the revised demonstration would help assist in developing improved procedures for the identification, investigation, and prosecution of potential Medicare fraud. The demonstration would help make sure that payments for home health services are appropriate through either pre-claim or postpayment review, thereby working towards the prevention and identification of potential fraud, waste, and abuse; the protection of Medicare Trust Funds from improper payments; and the reduction of Medicare appeals. Unfortunately, it makes the process more challenging for all agencies that are providing services and submitting claims in the impacted states to get paid.
CMS proposes initially implementing the demonstration in Illinois, Ohio, North Carolina, Florida, and Texas with the option to expand to other states in the Palmetto/JM jurisdiction.
Under this demonstration, 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% pre-claim review or 100% postpayment 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 pre-claim or postpayment 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% payment reduction on all claims submitted for home health services and may be subject to review by the Recovery Audit Contractor.
Implementation of this program can have crippling results on home health agencies, either by increasing paperwork burdens or worse, reductions in payment. Also, the demonstration allows CMS to collect a significant amount of data, which may then be used by the OIG and other regulators to look for fraudulent activity. CMS promotes the demonstration as a fraud-control technique in the home health arena, while also using it as tool which they claim could “reduce expenditures while maintaining or improving quality of care.” This leaves HHAs vulnerable. A comprehensive mitigation plan is necessary to address this new risk. Whether CMS and its contractors uncover what they consider to be “fraudulent” or “abusive” activities—or they simply reduce expenditures by denying payment on claims—HHAs are at risk.
Hiring outside experts can help you achieve positive outcomes, mitigate risk, and avoid several pitfalls, and a collaborative legal/consultative approach may provide the greatest benefit. A collaborative legal/consultative approach may provide the greatest benefit when navigating this process. A consultant can help address concerns and respond to requests by reviewing files and providing education and feedback to your team. Meanwhile, retaining an attorney can help protect your agency, provide a degree of protection for your communications, conduct an internal investigation and provide essential guidance for dealing with CMS, its contractors, and regulators. Attorney-Consultant teams provide the best overall value for demonstrations and audits. A collaborative legal/consultative approach can maximize the value to your agency while reducing the risks associated with the Demonstration, audits and enforcement activities. Having the expertise, staff, tools, and resources available at the right time and place for your agency is essential.
The van Halem Group has partnered with law firm K&L Gates to provide you the benefit of protection and expert advice you need. Contact us to learn more about the demonstration and the ways in which The van Halem Group can help, including:
- Clinical documentation review
- Electronic submission of documentation
- Claim Reporting and tracking
- Training and Education
- Appeals