CMS implementing Pre-Claim demonstration for Home Health Agency Services.
Home Health Agency (HHA) services are a critical part of the health care continuum and are instrumental in helping a patient with Medicare benefits recover after an illness or injury. The Medicare home health benefit allows beneficiaries who are deemed homebound to receive certain medically necessary services in their homes, which is a preferred setting for many beneficiaries.
Today, the Centers for Medicare & Medicaid Services (CMS) is taking important new steps to provide timely and appropriate home health services to Medicare beneficiaries, while protecting the Medicare Trust Funds and taxpayer funds from fraud and improper payments.
Maintaining Beneficiary Access to Care
Under this demonstration, physicians and clinicians participating in Medicare will continue to make health care decisions in coordination with their patients, including creating a care plan for the types of home health services a beneficiary needs. Once home health services are ordered by their Medicare physicians, the eligible beneficiary should be able to receive Medicare?s home health services immediately. The main change under this demonstration is that Home Health Agency (HHA)s will submit the supporting documentation while beneficiaries are receiving care. This earlier submission of documentation will undergo the new ?pre-claim review.? Pre-claim review does not change beneficiary eligibility standards or Medicare?s documentation requirements for home health care.
In most cases, the Home Health Agency (HHA) providing the care will gather all of the required documentation and submit it for pre-claim review. This is the same documentation they currently gather for payment, only HHAs will submit it earlier in the process. A beneficiary may also submit documentation for pre-claim review. Medicare will review the documentation to determine if all coverage requirements for home health services are met and will issue a pre-claim review decision generally within 10 days. If the documentation submitted was not sufficient, then the HHA (or beneficiary) may submit additional documentation to support the claim. Once sufficient documentation is submitted, Medicare will make timely payment on the home health services claim following the standard process.
Helping Home Health Agencies Avoid Errors
The pre-claim review demonstration will help educate Home Health Agency (HHA)s on what documentation is required and encourage them to submit the correct documentation, while still allowing the Home Health Agency to begin providing services and receive initial payments prior to the pre-claim review decision. The demonstration also aligns Medicare?s payment requirements and approach with commercial insurers, including some Medicare Advantage plans.
A Home Health Agency may resubmit the supporting documentation as many times as necessary during the pre-claim review. During the pre-claim review, Medicare will work closely with the HHA to explain what documentation is needed and why a prior submission was insufficient. Currently, the opportunity to fix home health documentation and resubmit a claim for payment is rare and typically only available in the administrative appeal process after a claim has been denied. This resubmission process helps Home Health Agency(HHA)s successfully submit the necessary documentation before submitting a final claim for payment. This new process should decrease improper payments because of insufficient documentation, as well as reduce the need for HHAs to appeal claims.
If a claim is ultimately not approved during the pre-claim process, then the final claim for payment will be denied, but the HHA may appeal that determination. If the HHA fails to submit a request for pre-claim review, but the final claim is submitted for payment, then the final claim will be subjected to a pre-payment medical review. In most cases, a beneficiary would not be liable for expenses in a home health claim that has been denied.