Prior Authorization Is Coming to Home Health Care

June 10, 2016

If you live in Illinois, Florida, Texas, Michigan or Massachusetts, you are the lucky home health care workers who get to pilot out the Medicare pre-claim review program. Due to opposition from 116 House of Representative members and 6 Senators so far, CMS has modified their program from the original conceived idea of “a prior authorization procedure that is similar to the Prior Authorization of Power Mobility Device”. Much of the concern had been centered around the delays that beneficiaries would experience waiting for authorizations to be confirmed before an agency could open their cases. The answer is pre-claim review.

So this is what we know so far. Implementation dates will begin “no earlier than” August 1, 2016 in Illinois, October 1, 2016 in Florida, December 1, 2016 in Texas and January 1, 2017 in Michigan and Massachusetts. While these dates do not appear to be set in stone, agencies should act as if they are to make sure that they are ready to comply.

Here’s the process as it has been explained so far. An agency will get their referral as usual, open the case and file the RAP. The agency has 30 days from the start of care date to submit documentation supporting medical necessity to their Medicare Administrative Contractor (MAC) via mail, fax or Electronic Submission of Medical Documentation (esMD) system (as of this writing, the specifics of the documentation or the submission have not been made available by the MAC). The MAC will return a favorable or unfavorable decision to the agency within 10 days with the reason for unfavorable determination. The agency may then appeal any unfavorable judgment and the MAC will return a decision within 20 days.

The agency will need to add the pre-claim review tracking number to the final claim for payment. If all the steps have been followed appropriately, claims should be paid as usual. If the pre-claim review was unfavorable, the final claim will be denied though the agency will still have the right to appeal the denial through the normal appeal channels. If the pre-claim review was not obtained, the claim will automatically go into pre-payment review. If the services and documentation were sufficient, the claim will be paid but a 25% penalty will be assessed for not obtaining the pre-claim review. Though there will be a three month grace period before this penalty begins to be processed for agencies in the affected areas.

What do you need to do now? Make sure you are signed up for e-mail updates with your MAC. They will be sending out more detailed information about how and what to submit as the deadline gets closer. They will also be confirming deadlines in the participating states. Call your software vendor and ensure that they will be ready for you to submit end of episode claims with the pre-claim review tracking numbers. Talk to your staff and make sure that everyone understands how important it is to have complete information on all clients to supply evidence of medical necessity to your MAC. Also, talk to your physicians and referral sources and make sure that your face-to-face documentation continues to support the need for home care services.

Finally, CMS has a few resources if you want more information: