Problems Pile Up as Pre-Claim Rolls on in Illinois

While the home health industry cheered after learning the Pre-Claim Review Demonstration from the Centers for Medicare & Medicaid Services (CMS) would be delayed ahead of start dates in four other states, the program is still likely to roll out—and is still in effect in Illinois.

“This is just a delay. It does not mean it has been eliminated altogether,” Nick Seabrook, managing director at Blacktree Healthcare Consulting, said during a recent webinar on pre-claim. “Illinois still has to go through these rules.”

As CMS works to educate doctors, agencies and Medicare Administrative Contractors (MACs) on the demonstration and claims process, home health care agencies need to remain ready and could learn a thing or two from the disastrous roll out in Illinois.


The Burden of Time

One of the biggest missteps that has been discovered in the demonstration in Illinois is the actually amount of time it takes to submit pre-claims for approval. While CMS assured home health agencies that the process would not add any administrative burden, as agencies would be submitting the same paperwork in the pre-claim process versus the regular claims process, that has proven to be untrue, according to Craig Mandeville, CEO and founder of Forcura.

In Illinois specifically, the process takes nearly an hour, Seabrook described. By comparison, one MAC, Palmetto, estimated that the process would take just just five to 10 minutes. One home health agency, Illinois-based Residential Home Health, put CMS’ estimate to the test in a video that documented the process.


“There are horror stories that we’ve been hearing,” Seabrook said of the claims process during the webinar. “An agency in Illinois did a timed study and a video. Palmetto estimated a five to 10-minute process. The agency’s video walked through the whole process, and it shows the submission process from start to finish took 51 minutes.”

That grossly underestimated figure is per claim, according to Seabrook. While a lot of the pre-claim submissions are done online, the process is time-consuming, and there are issues specific to using an online portal, as well.

“You cannot save and come back later, or the website will time out,” Mandeville said. “You want the team members to be very dedicated and not interrupted to do the work and conduct their uploading process.”

Once pre-claims are submitted, agencies must wait up to 10 days before receiving an approval or being told to resubmit their claims. Resubmission responses can take up to 20 days. These response times, coupled with a very low reported affirmation rate in Illinois, is likely to lead to “significant delays,” Seabrook said.

“Some agencies have said they won’t admit any patients until they get affirmations back,” he said “They can’t take the risk of not getting reimbursed for those services.”

Best Practices

To facilitate the pre-claims process, some home health agencies have hired or are considering hiring additional help to focus on the submissions process. However, it’s essential that agencies know their documentation requirements before hiring additional staff.

“It’s the same requirements, but they must be organized in an articulate fashion and delivered as quickly as possible,” Matt Challberg, director of business development at Forcura, said of organizing the pre-claim paperwork. “The more effectively organized the packet, the more likely to have a positive outcome of a potential affirmation.”

That means that home health administrators need to be trained on how to package the claims.

Additionally, notifying partners can help an agency move the submission process along. CMS has stated it will step up its education outreach to physicians, in part because obtaining their signature on the care plan has potentially slowed down the submission process. However, home health agencies can take this step, too, by notifying their referring physicians about pre-claim.

“That clear line of communication can help get that better documentation on the front end,” Challberg said. “More information in a concise manner up front, as quickly as possible, will be more effective and efficient.”

Lastly, once pre-claims are submitted, it’s essential that agencies stay on top of their claims throughout the process by tracking their documents and corresponding numbers. In doing so, it’s also important to have a specific process in place for tracking and following up with resubmissions.

Written by Amy Baxter

Companies featured in this article:

, ,