Update on the Delay for the Home Health Pre-Claim Review Demonstration

The Centers for Medicare & Medicaid Services (CMS) announced a delay for the expansion of the Home Health Pre-Claim Review Demonstration. The Home Health Pre-Claim Review Demonstration (PCRD) began in August in Illinois, and then CMS planned to move the demonstration into Florida, Texas, Massachusetts, and Michigan. New York is not part of the demonstration. As a result of what occurred in Illinois, CMS believes that additional education efforts will be helpful before expansion into the other states. The education efforts will focus on how to submit pre-claim review requests, documentation requirements, and common reasons for non-affirmation.     

It has been reported that home health providers in Illinois experienced high denial rates on their claims submissions, inconsistency in the pre-claim process, and significant administrative burdens in their attempts to comply with the regulations.

We had previously reported on PCRD, which is a three-year Medicare pre-claim review demonstration for home health services in the states mentioned above. Earlier in the process, CMS had proposed a demonstration on prior authorization that evolved into PCRD. In the pre-claim demonstration, CMS wants to test whether pre-claim review improves methods for the identification, investigation, and prosecution of Medicare fraud occurring among Home Health Agencies (HHAs) providing services to people with Medicare benefits.

According to CMS, the pre-claim review demonstration does not create new clinical documentation requirements. HHAs will submit the same information they currently submit for payment, but will do so earlier in the process. HHAs must submit a request for pre-claim review to the Medicare Administrative Contractor (MAC) for each episode of care. The pre-claim review request may be submitted at any time before the final claim is submitted, and the review process must occur before the final claim is submitted for payment. We have the same concerns that we voiced earlier in the demonstration: that this may delay access to care and create more administrative and time-consuming problems for HHAs.

As a reminder, CMS updated the 11-page document on PCRD, Pre-claim Review Demonstration for Home Health Services Frequently Asked Questions. Please note the areas highlighted in red. CMS has also posted a PCRD Operational Guidance document.

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

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