With all the various changes CMS is making in the 2019, one change that may have been missed, and yet could have a huge financial impact on providers in Texas, Illinois, Ohio, Florida, and North Carolina, is Review Choice Demonstration. If you are asking “how much could our revenue could be impacted by this change?”; the answer is “by as much as 25%”.

Pre-Claim Review is now Review Choice Demonstration

In June 2016, CMS announced implementation of a three-year Home Health Pre-Claim Review Demonstration. The demonstration was designed to test whether a Pre-Claim Review (PCR) process would improve the identification, investigation, and prosecution of Medicare fraud occurring among home health agencies (HHAs).

On April 1, 2017, CMS suspended Pre-Claim Review to consider a number of changes for structural improvement of the program. Subsequently, on May 29, 2018, it issued a new proposal to re-instate the program with changes, calling it “Review Choice Demonstration.” CMS revised the Demonstration to include more flexibility and choice for HHAs, and incorporated risk-based changes to reward agencies who show compliance.

CMS said the Pre-Claim Review Demonstration would not create new clinical documentation requirements and that HHAs would submit the same information they currently submit for payment, just earlier in the process. Medicare would review the documentation to determine if all coverage requirements for home health services were met and would issue a PCR decision within ten days. If the documentation submitted was not sufficient, then the HHA (or beneficiary) would need to submit additional documentation to support the claim. Once sufficient documentation was submitted, Medicare would pay the claim following standard processes. If a claim was not approved during the pre-claim process, then final payment would be denied, but the HHA could submit an appeal.

If an HHA failed to submit a request for pre-claim review, but the final claim was submitted for payment, then the final claim would be subject to a pre-payment medical review. If the claim was determined to be eligible for payment, the HHA would incur a 25% penalty. This penalty cannot be appealed and HHAs cannot seek payment from the beneficiary.

 

How you can protect your business

When the Pre-claim Review was first rolled out in Illinois in 2016, there were a number of bumps in the road, and HHAs needed to learn some challenging lessons through trial and error. Here are some things you can do today to avoid many of those challenges and keep your business running smoothly during this transition.

  1. Begin your preparations TODAY. One common problem when the Pre-claim Review first started was a lack of understanding regarding what information was needed for a claim. MACs, such as Palmetto GBA, will be looking for specific information during a claims review, and if that information is not found, the review will be pushed back to the HHA for resubmission. Multiple resubmissions have the effect of slowing down an HHA’s business. And if revenues associated with resubmissions fails to come into the HHA on a timely manner, the HHA’s business can grind to a halt. HHAs found that by working with a company like Palmetto GBA, they could learn what information is needed for a successful submission. Palmetto is offering a monthly teleconference where providers can ask questions about Review Choice Demonstrations. Dates for those teleconferences can be found here: https://www.palmettogba.com/event/pgbaevent.nsf/SeriesDetails.xsp?EventID=B5GLHT7258
  2. Review Your Staffing Structure NOW. Surveys from the Pre-Claim Review trials show that the time for submitting Pre-Claim Reviews took far longer than CMS estimated, and this caught many agencies by surprise. Besides the steep learning curve of what information is needed for submission, some agencies reported each submission took an hour to complete. For some HHAs, hiring a new employee to manage paperwork is a feasible option, and yet for most HHAs, they will need to find efficiencies within their staffing structure.

How Viscare Can Help

Don’t be one of the HHAs who are unprepared for these changes. Surveys from the Pre-claim Review show us that most HHAs will NOT be prepared for the rollout of Review Choice Demonstration. You don’t have to be one of those HHAs who will lose revenues because of the poor quality of your submitted documents, the mismanagement of your customer facing personnel, and missed calls. And you don’t have to overwhelm your office staff and stifle your business growth by adding more paperwork to their current job. You can be prepared for the roll out of Review Choice Demonstration, and not lose money, stifle your growth, and burden your staff. But to do that, you will need help. And at Viscare, we can help you with these changes and help you grow your business.

At Viscare, we’re helping HHAs fight lost revenue and staffing concerns associated with Review Choice Demonstration. With our “Agency Aid” software and “Clinician App” we are able to provide HHAs with a level of automation so that clinicians are seamlessly directed to the right patient, missed calls are eliminated because results are tracked in real time and automatically rerouted to the next best clinician, and your office staff can be focused on managing new submissions, monitoring the quality of calls, and ultimately growing your business.

Why not contact us today and let’s discuss how Viscare can help you efficiently staff your business, protect your revenue, and grow your business. You can contact us by email at: sales@viscare.com

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