On May 31, 2018 a Federal Register Notice was submitted by the Centers for Medicare & Medicaid Services (CMS) for public commentary on the revised Pre-Claim Review demonstration (PCRD). Until July 30, the general public may share their comments and opinions on the proposed action.
The revised demonstration offers home health providers three options when submitting claims to CMS:
- Pre-claim review – Providers may submit pre-claim documentation on 100% of claims until a target affirmation is reached. They will then be allowed to stop submitting pre-claim review, but can be periodically checked for compliance.
- Post-payment review – Providers can choose to show compliance by submitting all claims for post-payment review procedures, once the final claim has been handled. Again, once a target affirmation is reached, they may stop submissions but may be checked for compliance.
- Minimal post-payment review with 25% payment reduction – Those providers who choose not to submit claims through the review methods above may do so, but will receive a 25% payment reduction on all claims and are subject to scrutiny by the Recovery Audit Contractors.
According to the FAQ provided on the CMS website, the PCRD should have “minimal effects” on beneficiaries. The pre-claim review is meant to be submitted after intake and start of services, but before the final claim is submitted.
The revised PCRD would take effect no sooner than October 1, 2018, beginning in Illinois. The states of Ohio, North Carolina, Texas and Florida would follow, although no dates have been provided for implementation.
Interested parties have two options for voicing their opinions to CMS on the revised PCRD through July 30, 2018.
- Visit http://www.regulations.gov to submit your comments electronically. Use the “comment or submission” or “more search options” instructions to locate the correct collection documents to submit your comments.
- Comments can be submitted by mail at the following address:
CMS, Office of Strategic Operations and Regulatory Affairs
Division of Regulations Development
Attention: Document Identifier/OMB Control Number 0938-1311
7500 Security Boulevard
Baltimore, MD 21244-1850
The Centers for Medicare & Medicaid Services (CMS) announced on March 31, 2017, that it has suspended the Pre-Claim Review demonstration program (PCRD). The announcement states:
“As of April 1, 2017, the Pre-Claim Review demonstration will be paused for at least 30 days in Illinois. The demonstration will not expand to Florida on April 1, 2017.
“After March 31, 2017, and continuing throughout the pause, the Medicare Administrative Contractors will not accept any Pre-Claim Review requests. During the pause, home health claims can be submitted for payment and will be paid under normal claim processing rules. CMS will notify providers at least 30 days in advance via an update to this website of further developments related to the demonstration.”
Read the March 31 announcement from CMS here.
CMS announced on Dec. 19, 2016, that it will expand the Pre-Claim Review Demonstration for Home Health Services to Florida for episodes of care that begin on or after April 1, 2017. Additional education has been provided by CMS on how to submit pre-claim review requests, documentation requirements, and common reasons for non-affirmation decisions. Medicare Administrative Contractors are continuing educational outreach in Florida to ensure that providers are informed. See the Dec.19 fact sheet release from CMS for more details.
Illinois was the first state to implement PCRD; Texas, Michigan and Massachusetts are currently in line to implement after Florida, although they have not yet been scheduled.
- Home health providers are required to obtain a pre-claim review for home health services prior to submission of a final claim.
- The pre-claim review demonstration does not create new documentation requirements, according to CMS.
- Affirmative decisions on pre-claim reviews will be issued a Unique Tracking Number (UTN) that must be included when submitting the final claim to be eligible for payment.
- Claims submitted without a pre-claim review decision can reduce payment amounts and/or lengthen revenue cycle time.
- After 3 months, claims submitted without a pre-claim review decision will be paid with a 25% reduction of the full claim amount. This decision cannot be appealed.
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