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GAO wants Pre-Claim Review to resume.<\/em><\/strong><\/span><\/p>\n Medicare is revealing more details about its resurrected Pre-Claim Review demonstration project, which it\u2019s now calling the \u201cReview Choice Demonstration.\u201d But many specifics remain cloudy.<\/p>\n One of the most pressing questions for home health agencies in the five states the\u00a0Centers for Medicare & Medicaid Services\u00a0<\/strong>identified for the PCR\/RCD demo was the implementation schedule. In its May 31\u00a0Federal Register\u00a0<\/em>notice about the demo, CMS merely said that it was proposing \u201cinitially implementing the demonstration in Illinois, Ohio, North Carolina, Florida, and Texas with the option to expand to other states in the Palmetto\/JM jurisdiction.\u201d<\/p>\n In a PCR\/RCD question-and-answer set released May 31, CMS clarified that it would group the five demo states into three stages for implementation. \u201cCMS will stagger implementation of the Demonstration, beginning with the state of Illinois, then expanding to Ohio and North Carolina, and later to Texas and Florida,\u201d the Q&A say.<\/p>\n CMS also specifies that \u201cthe revised demonstration will begin no earlier than October 1, 2018\u201d and the demo will last five years.<\/p>\n However, affected HHAs require more specifics than that, maintains\u00a0William Dombi\u00a0<\/strong>with the\u00a0National Association for Home Care & Hospice<\/strong>. \u201cWe need the timetable that CMS expects to use to roll out RCD in the various states,\u201d Dombi says.<\/p>\n GAO Is Not On Your Side<\/strong><\/span><\/p>\n Many home care industry members were taken by surprise when CMS announced its intention to bring back PCR. \u201cIt seems like pre-claim review is becoming the Lazarus of the home care industry,\u201d observes Washington, D.C.-based healthcare attorney\u00a0Elizabeth Hogue<\/strong>.<\/p>\n CMS\u2019s notice came after an April\u00a0Government Accountability Office\u00a0<\/strong>report recommending that CMS resume \u201cthe paused home health services demonstration.\u201d The GAO also wants CMS to identify \u201cnew opportunities for expanding prior authorization to additional items and services with high unnecessary utilization and high improper payment rates,\u201d and take other prior authorization-boosting steps.<\/p>\n Perhaps in anticipation of industry opposition, CMS included some preventive justification for its resurrection of the much-reviled program. \u201cThis revised demonstration would help assist in developing improved procedures for the identification, investigation, and prosecution of potential Medicare fraud,\u201d CMS says. \u201cThe Demonstration furthers CMS\u2019 efforts to protect the Medicare Trust Funds from improper payments and to reduce Medicare appeals.\u201d<\/p>\n The agency also downplays any potential access problems caused by the demo. \u201cThe revised demonstration should have minimal effect on beneficiaries and does not alter the Medicare home health benefit,\u201d CMS maintains in the Q&As. \u201cUnder the pre-claim option, the pre-claim review request can occur after home health services have started.\u201d CMS spells out the difference between prior authorization and RCD. \u201cWith pre-claim review, services can begin,\u201d the agency says.<\/p>\n And CMS plays up the changes it makes to the demo. \u201cCMS is revising the Demonstration to incorporate more flexibility and choice for providers, as well as risk-based changes to reward providers who show compliance with Medicare home health policies,\u201d it says.<\/p>\n But home care providers and their advocates say the changes are mostly window dressing that don\u2019t mitigate the program\u2019s burden and other shortcomings.<\/p>\n Original PCR Caused Cash Flow Delays, Access Problems<\/strong><\/span><\/p>\n Chief among RCD\u2019s flaws is its ineffectiveness, particularly in comparison to its added workload level. \u201cI am unclear how pre-claim review really addresses the issue of fraud and abuse,\u201d Hogue contends. \u201cThe MAC gets an initial \u2018snapshot\u2019 of the patient\u2019s condition, which may meet applicable criteria, but the bulk of the information about any episode isn\u2019t going to undergo pre-claim review.\u201d<\/p>\n Plus:<\/span>\u00a0<\/strong>\u201cJust because an agency achieves a certain rate of \u2018compliance\u2019 and is removed from review doesn\u2019t mean that all subsequent claims will meet applicable requirements,\u201d Hogue adds. \u201cI just don\u2019t see the real value.\u201d<\/p>\n During PCR\u2019s previous iteration, it \u201chad a sizable impact on patients and providers in the state of Illinois, damaging cash flow and causing delay in treatment in some cases,\u201d NAHC warns in its member newsletter.<\/p>\n While CMS touts RCD \u201cas a choice of options for home health agencies, the options presented are two with increased paperwork burdens and one that would financially cripple a home health agency with a 25 percent payment reduction,\u201d Dombi protests in the newsletter. \u201cWe certainly do not want to see nurses, therapists, and home care personnel spending their days chasing down paperwork at the expense of patient care.\u201d<\/p>\n Unfair:<\/span>\u00a0<\/strong>\u201cNo other health care sector is forced to submit every care claim for review or face a punishing 25 percent pay cut,\u201d NAHC points out.<\/p>\n \u201cIt is important to remember that when PCR was halted originally it did\u00a0not\u00a0<\/em>find evidence of unnecessary care or services provided that were not meant to be covered,\u201d NAHC insists. \u201cInstead, PCR merely found correctable documentation issues, a problem that was fixed and was hardly worth the pain inflicted on home health providers and patients.\u201d<\/p>\n How Will 90% Option Work?<\/strong><\/span><\/p>\n While the industry gears up to oppose the demo (see story, this page<\/em>), it also is awaiting further details about CMS\u2019s plan for the program. \u201cAdditional information will be released in the coming months,\u201d CMS pledges in the Q&As.<\/p>\n The list of outstanding questions about RCD is long, Dombi says. In addition to the rollout timetable, HHAs need to know \u201cthe specifics on how the 90 percent performance exemption will work, how CMS intends to provide training to HHAs on RCD best practices, what CMS will be doing about staffing resources at\u00a0Palmetto GBA\u00a0<\/strong>to handle the new workload, what plan CMS has to conduct real time analyses of what is happening with RCD, and what oversight CMS will conduct to prevent harm to patients that could be triggered by review errors,\u201d he notes.<\/p>\n Note: A link to the Q&As is in the \u201cDownloads\u201d box at\u00a0www.cms.gov\/Research-Statistics-Data-and-Systems\/Monitoring-Programs\/Medicare-FFS-Compliance-Programs\/Review-Choice-Demonstration\/Review-Choice-Demonstration-for-Home-Health-Services.html<\/a>.<\/em><\/p>\n Source- SuperCoder<\/span><\/i><\/a><\/p>\n","protected":false},"excerpt":{"rendered":" GAO wants Pre-Claim Review to resume. Medicare is revealing more details about its resurrected Pre-Claim Review demonstration project, which it\u2019s now calling the \u201cReview Choice Demonstration.\u201d But many specifics remain … Continue Reading →<\/a><\/p>\n","protected":false},"author":1,"featured_media":321,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[8,5],"tags":[11,12,13,14],"class_list":["post-320","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-compliance","category-reimbursement","tag-home-care","tag-hospice","tag-ltc","tag-snf"],"_links":{"self":[{"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/posts\/320","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/comments?post=320"}],"version-history":[{"count":1,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/posts\/320\/revisions"}],"predecessor-version":[{"id":322,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/posts\/320\/revisions\/322"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/media\/321"}],"wp:attachment":[{"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/media?parent=320"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/categories?post=320"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/tags?post=320"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}