Posted on Tuesday, December 6, 2016 2:20 PM
According to the Centers for Medicare & Medicaid Services (CMS), affirmation rates for the Pre-Claim Review Demonstration (PCRD) currently underway in Illinois continue to rise in the program’s 17th week.
In the early months of the program’s implementation in Lincoln, IL, home health industry groups felt that some agencies were potentially holding back some of their pre-claim review requests. Luckily, the data shows that affirmation rates for pre-claim requests are gradually trending up. The first eight weeks of the program demonstrated that only 66% of claims were either partially or fully affirmed.
“People are starting to figure it out,” Katharine Eastvold, director of regulatory and public affairs at the Illinois Home care & Hospice Council (IHHC) told Home Health Care News. “But the fact remains it is a very time-consuming process that’s causing a lot of frustrations. It takes time and effort away from patient care. That’s time our agencies and providers could be spending doing what they need to do for their patients.”
However, not all agencies are participating in the model. Data from October reported that less than half of agencies in Illinois were making PCR submissions, according to Eastvold.
“Why there are so many agencies out there that seem to not be doing PCRD is a mystery to us,” Eastvold said. “We haven’t seen an update since October on the number of agencies that file PCR. It was fewer than half of all agencies, and we are asking CMS for an updated number.”
CMS’ high affirmation rates reported much higher than what some agencies originally told HHCN.
Between August 3 and October 31, 2016, the agency reported that CMS received 23,061 pre-claim review requests from home health agencies in Illinois. Additionally, there were 80,961 requests for anticipated payment (RAPs). A claim submission is eventually anticipated for each RAP, and providers have until they submit a final claim to submit pre-claim review requests.
“Therefore, it is possible that requests associated with many of these RAPs will be submitted through the pre-claim review process.”
According to CMS, home health agencies were in a grace period to submit pre-claim review requests through November 1, as long as agencies did not “choose to take advantage of the pre-claim review process, when the final claim is submitted, it will be subjected to pre-payment review.”
According to IHHC, now that the grace period has lapsed, agencies are less likely to be holding back pre-claim review requests.
“We have not heard from our members that they are holding requests back,” Eastvold told HHCN. “The grace period is over and [CMS] is taking 25% off the final payment if a PCR request was not filed. As far as the agencies we’ve talked to and our members, that’s not what they want. They are really getting through their backlogs and submitting as many claims as they can.”
The newest data comes as advocates have cracked down on their efforts to delay the implementation of the program elsewhere and pause the model in Illinois.
“Ultimately we would like to see the program suspended or terminated,” Eastvold said. “In the meantime, we would like to see CMS take a look at the data and the agencies that are doing PCR that have gotten the hang of it. Then there is a cohort that aren’t doing it at all for whatever reason, and maybe they could look at targeting that group. It’s a huge burden on our members, but also the tax payer.”
Corridor offers a variety of services to help you navigate through the CMS requirements – including:
• Readiness Assessment
• Outsourced Services
• Documentation Review
Call Corridor today for help with Pre-Claim Review. 1-866-263-3795
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