Pre-Claim Affirmations Hit 82% in Latest CMS Data

After more than three months of the pre-claim review demonstration underway in Illinois, new data from the Centers for Medicare & Medicaid Services (CMS) reveals that the vast majority of requests have been fully or partially affirmed.

In week 14 of the demonstration, 82% of pre-claim review requests in Illinois received provisional affirmation, either fully or partially affirmed, the agency announced. The data shows stark improvement from the first weeks of the program; during the first eight weeks, just 66% of pre-claim review requests were affirmed.

However, home health agencies and industry groups alike have pushed back against the high affirmation rates, citing that partial affirmations still require agencies to resubmit their pre-claim requests.

This pushback may have led CMS to further clarify the data in the latest release—77% of pre-claim requests were fully affirmed while 5% were partially affirmed, according to the agency. Home health care providers in Illinois have seen a wide variance in their affirmation numbers, with some reporting very low affirmation rates, particularly early on in the demonstration.

While CMS’ data shows improvement, the home health industry has also largely blamed a dip in M&A activity during the third quarter of the year on the burdens of the pre-claim program and the fears of it spreading to other pilot states.

In the latest data release, CMS also clarified what it means when requests are only partially affirmed and the options agencies have for this designation of their submissions.

“A partially affirmed decision indicates at least one service submitted on the pre-claim review request was provisionally affirmed and at least one service was non-affirmed,” CMS clarified. “For example, a pre-claim review request may be submitted for skilled nursing services, physical therapy and speech therapy. However, only the skilled nursing services and physical therapy are provisionally affirmed, which the speech therapy is non-affirmed.”

Agencies with partially affirmed decision can decide to “take no further action,” CMS stated. An agency can submit its final claims with provisionally affirmed and non-affirmed services, though its non-affirmed services will ultimately be denied.

Agencies can also resubmit their requests with additional documentation for the non-affirmed services. Home health agencies are allowed to resubmit requests as many times as they wish.

At this time, the implementation of the program in Florida, Texas, Massachusetts and Michigan has been paused. Industry groups have vowed to work on further delaying the program, while legislation has been introduced to place a one-year moratorium on the demonstration.

Written by Amy Baxter

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