Latest Developments on the Home Health Pre-Claim Review Demonstration (PCRD)

LeadingAge NY continues to follow the latest developments on the Centers for Medicare and Medicaid Services (CMS) Home Health Pre-Claim Review Demonstration (PCRD). The PCRD began in August in Illinois, and then CMS had planned to move the demonstration into Florida, Texas, Massachusetts, and Michigan. Based on early information from Illinois, CMS believes that additional education efforts will be helpful before any expansion of the demonstration to other states. New York is not part of the demonstration at this time.

The education efforts will focus on how to submit pre-claim review requests, documentation requirements, and common reasons for non-affirmation. This information is currently available through the CERT program on HHA documentation errors. The money spend on the PCRD could be reallocated and used to educate providers, physicians, patients, and others on targeted Medicare coverage requirements, eligibility, and other issues mentioned above. Please note, on page 2 of the Early Data Fact Sheet from Illinois, the reasons why requests are being denied.

The three latest developments are:

1. Early Data Fact Sheet from Illinois.
2. CMS updated the Pre-Claim Review Demonstration for Home Health Services Frequently Asked Questions. Please note the areas highlighted in red.
3. Percentage of Affirmed/Partially Affirmed Pre-Claim Review Requests in Illinois: The percentage of claims that are not being denied appear to be improving as of Oct. 21^st. However, what is of concern is CMS’ intent: “beginning November 3, 2016, claims submitted for payment without a pre-claim review decision will be subject to a 25 percent payment reduction if found to be payable.”

LeadingAge NY will continue to keep members posted on any other developments on PCRD.

Contact: Cheryl Udell, cudell@leadingageny.org, 518-867-8871