With just over one month before the start of the Centers for Medicare & Medicaid Services’ (CMS) Pre-Claim Review Demonstration for Home Health Services, agencies in the five-state pilot program are eagerly looking for clarification on compliance requirements.
The three-year program will begin in Illinois on August 1, with Florida and Texas beginning later this year and Michigan and Massachusetts starting in 2017. Despite CMS’ reassurances to home health agencies that no new documentation is required for the pre-claim demonstration, providers from across the country expressed lingering questions Tuesday on a public call with CMS officials.
Notably, multiple home health professionals voiced their concerns over the requirement that a physician’s signature be included in the plan of care within a pre-claim request. Many professionals, including a home care association representative, indicated that securing a physician’s signature can be a significant burden for a home health agency within a shortened timeframe. Currently, it can take up to several weeks to send forms back and forth from a physician before a home health agency can get a signature for a plan of care to submit a final claim.
Physicians “have no skin in the game,” and are unlikely to respond in a timely manner for home health agencies to send in their pre-claim submissions with all the required documentation, one questioner argued. Other agencies pointed out they already spend “a lot of man hours” obtaining physician signatures. Speeding up this requirement worried many.
CMS will perform some educational outreach to physicians in the demonstration states to encourage the pre-claim process, officials responded, but they remained rigid that the requirement will be included.
“The care plan must be signed [by a physician] in pre-claim reviews,” CMS officials said. “We are hearing your concern about needing to educate physicians. We want to be clear we are rolling this out to physicians, as well.”
A physician’s signature is already a requirement for a plan of care in a final claim, officials also stressed. A physician’s order for home health care services is part of a home health agency’s requirement to prove medical necessity as part of its Medicare claims.
The new model requires home health agencies to submit pre-claim requests for approval prior to submitting a final claim, and is set up so that agencies can go through this process while providing care to patients, according to CMS officials.
One Illinois home health care provider preparing for the demonstration in August says the physician signature is just one part of compliance measures that will have to be completed more efficiently and accurately.
“Home health agencies should be more focused on the compliance of their field clinicians,” Marvin Javellana, CEO and founder of Des Plaines, Illinois-based Better Care Home Health Inc., told Home Health Care News. “That means prompt submission of the OASIS, quick and accurate turnaround time for quality assurance and coding in order to generate the plan of care. The next challenge is getting the physician to sign off on the plan of care, which has always been a challenges unless the agency has a relationship with the facility or practice.”
CMS officials also detailed that any non-affirmed pre-claim requests will include a detailed review of why the pre-claim was not affirmed so agencies can resubmit with correct documentation. Agencies can resubmit pre-claim requests as many times as it takes to get approval before a final claim. Pre-claim submissions that are not affirmed do not count toward an agency’s claim denial rate.
“All of this allows for the early submission of the ‘pre-claim review’ documents and gives the agency enough time and submission tries in the event that the pre-claim is denied,” Javellana added. “It is not an added burden if the home health agency is doing it right, but a matter of making it tight.”
Written by Amy Baxter