No Pre-claim? Business as Usual, Right?

April 4, 2017

Wrong and wrong. While it’s true that starting April 1st the pre-claim review demonstration has been paused before it could start in Florida, and that pause has been extended to Illinois for at least 30 days, this is not the definitive end of the pre-claim process. And it should not be an excuse to relax agency documentation standards in the least.

Remember – the paperwork required for the pre-claim review was never meant to be an additional expectation of clinical record contents. Whether you operate in Illinois or not, it is worth reviewing the denial reasons, the educational materials, and the different articles about the pre-claim process to ensure that your face-to-face and medical necessity documentation meets the requirements. Because regardless of whether pre-claim continues in its current form or some other iteration, agencies are still subject to ADRs, Probe and Educate reviews, Recovery Audit Contractor (RAC) reviews, Zone Program Integrity Contractor (ZPIC) reviews, and other targeted reviews based on HIPPS codes, geographic area, and more.

Interestingly and tellingly we think, some of our Illinois clients have expressed that even though the pre-claim process started out rough, it morphed into a nice collaboration with Palmetto, where fiscal intermediary reviewers would call and provide individual education on non-affirmed pre-claim episodes. That education resulted in incidences of non-affirmed codes being almost completely eliminated with the agencies feeling like they have a much better sense of what is expected of face-to-face documentation and how to identify when it falls short.

According to a NAHC representative who met with CMS Administrator Seema Verma about the pre-claim review process, CMS intends to keep aspects of the pre-claim review program going in a modified version. Voluntary participation in exchange for exemption from post-payment review (unless fraud is suspected) and targeting first episodes, certain diagnoses, and non-compliant agencies are changes being considered. NAHC’s article on the subject confirms as much.

So for the short term, it appears that Illinois and Florida have a bit of a reprieve while CMS hammers out the details of the new pre-claim program. Smart agencies will seize this opportunity to continue to audit documentation for compliance and ensure that processes are in place to be prepared for whatever the future holds. In the meantime, round 2 of the Probe and Educate Review process started in December, 2016 and was expected to go for a year. With reviewers freed up from pre-claim documentation, we can only guess that we will see an increase in those Probe and Educate cases and potentially other targeted ADRs.

Be prepared! Make certain that the face-to-face encounter MD or Non-Physician Practitioner (NPP) progress notes meet all requirements. To brush up on what is needed on a face-to-face progress note, please review “Step I” in our recent article on home health pre-claim review submissions. Audit clinical documentation for medical necessity and homebound status – ensure those notes can stand independently and make sense all together. For any paper documentation, verify that it is legible and that all the documentation is available in the event of an audit or survey.