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11/2/2016
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MEDICARE HOME HEALTH PRE CLAIM
REVIEW REQUIREMENT
Presented by Providers Association for Home Health & Hospice Agencies
Agenda
l Medicare Pre Claim Review− Purpose− Impact− Requirements
Purpose
The Centers for Medicare & Medicaid Services (CMS) is implementing a three-year Medicare pre-claim review
demonstration for home health services beginning in 2016 and in 2017.
CMS is testing whether pre-claim review improves methods for
1)Identification, 2)Investigation, and 3)Prosecution of Medicare fraud
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Purpose Cont.
Pre Claim Review Fact Sheet (6/8/16)
In 2015, home health claims had a 59 percent improper payment rate, and a large proportion of the improper payment rate was because of insufficient documentation.
Through this demonstration, CMS aims to test the level of resources required for the prevention of fraud instead of engaging in “pay and chase” and to determine the feasibility of performing pre-claim review to prevent payment for services that have high incidences of fraud.
Basic Information
Medicare Pre-Claim review
PCR for short
The tentative start date is January 1, 2016 -in Texas
It will effect 5 states for now.
5 StatesèThe Pre-claim Review will affects Home Health
Agencies in five states. The initial three-year pre-claim review demonstration began in Illinois on August 1, 2015 and will roll out to Florida, Texas, Michigan and Massachusetts.
è Illinois - August 3, 2016èFlorida - November 1, 2016èTexas - December 1, 2016èMichigan - January 1, 2017èMassachusetts - January 1, 2017
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PUSH Back against PCRFrom Home Health Care News (online article titled “New Legislation Would Delay Pre-Claim One Year”) 9/28/16 by Amy Baxter
Pre-Claim Undermines Seniors’ Health (PUSH) Act
Representatives Tom Price (R-GA-6) and James McGovern (D-MA-2)
PUSH Back against PCR cont.Rep. Price wrote to Congressional members about the demonstration, saying it “is creating barriers to care and forcing providers to incur significant unnecessary burdens to support an overly broad, untargeted and ineffective demonstration,” the National Association for Home Care & Hospice (NAHC) reported.
Illinois Fact Sheet (10/5/16)
èHome health care agencies in Illinois began the process August 3.
è“Based on early information from Illinois, CMS believes additional education efforts will be helpful before expansion of the demonstration to other states; therefore, we will not move forward with initiating the demonstration in Florida in October,”
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Illinois Fact Sheet (10/5/16) cont.
Provisional Affirmation Rate:è “Over the first eight weeks, provisional
affirmation rates of pre-claim review requests have been increasing, meaning more requests are getting positive decisions.”
Illinois Fact Sheet (10/5/16) cont.
Reasons for Non-Affirmation:
Illinois Fact Sheet (10/5/16) cont.Ongoing and Enhanced Education:
“Going forward, CMS and the MACs will be conducting enhanced education both in Illinois and the next state where the demonstration will be implemented, Florida, to provide HHAs, physicians, beneficiaries, and other stakeholders with important information about the home health benefit and the demonstration.”
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Illinois Fact Sheet (10/21/16)Affirmation rate continues to increase:
“As of week 11, the majority (78 percent) of pre-claim review requests, received a provisionally affirmed or partially affirmed decision. Pre-claim review requests may include one or more home health services. A partially affirmed decision indicates at least one service was provisionally affirmed.”
Illinois Fact Sheet (10/21/16) cont.Provisional Affirmation Rate:
What about TexasThe start dates for Florida, Texas, Michigan, and Massachusetts have not been announced; however, CMS will provide at least 30 days’ notice on its website prior to beginning in any state. CMS continues to expect a staggered start, beginning with Florida.
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How is it supposed to work?1)It's not supposed to create new clinical
documentation requirements. 2)HHAs will submit the same information they
currently submit for payment, but earlier in the process.
3)Supposedly, all relevant coverage and clinical documentation requirements are met before the claim is submitted for payment.
4)It's not supposed to delay care to Medicare beneficiaries and should not alter the Medicare home health benefit
How is it supposed to work? Cont.What is included in PCR?è SOC
è ROC
è Changes in Condition
è Recertification
è Transfers – Accepted
è Additions of disciplines
è Eg. if MD adds PT you need to resubmit
How is it supposed to work? Cont.What is not included in PCR?è Request for Anticipated Payment (RAP)è No changesè Submit as usualè Encouraged to submit prior to submitting pre claim review
è Low-Utilization Payment Adjustmen (LUPA)è Not subject to PCR processè Other services under 60 days but more than 4 visits are
still subject to PCR
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How is it supposed to work? Cont.Submitting a PCR is voluntary
The claim will still be subject to pre-payment review
The claim will be subjected to a 25 % payment reductionWhich can NOT be appealedNor can it be billed to the beneficiary
How is it supposed to work? Cont.CMS informational letter to physicians.
Home Health Agencies can give the letter to physicians reminding them of their responsibility to provide the documentation.
If the physician and/or facility will still not provide the documentation, Home Health Agencies should notify their MAC or CMS (at [email protected]) of the uncooperative physicians and/or facilities.
How is it supposed to work? Cont.Submitting Facts:è The pre-claim review request may be submitted at any
time before the final claim is submitted.è The pre-claim review should be submitted when the
Home Health Agency has obtained all required documentation from the medical record to support medical necessity and demonstrate eligibility requirements are met.
è The pre-claim review process, including submission of the request and receiving the Unique Tracking Number (UTN), must occur before the final claim is submitted for payment.
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How is it supposed to work? Cont.Submitting Facts:è This includes resubmissions after receiving a non-
affirmed decision. Pre-claim review must be requested for each episode of care.
è A submitter is allowed an unlimited number of resubmissions for pre-claim review requests that have not been affirmed
è The demonstration only applies to those episodes of care that begin on or after the start date of the demonstration in the state where the service will or is being rendered
How is it supposed to work? Cont.Necessary Items:
èBeneficiary information
èCertifying Practitioner information
èHHA information
Submitter information
Required Documentation (from MD)
Misc. Information (dates, state ect)
Portal Entry
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Provider Information
Beneficiary Information
Claim Information
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Validation of Benificiary Information
Entering Documentation
Name of physician/practitioner
NPI number
Provider Transaction Acess Number (PTAN) – this is optional
Physician/practitioner address
Physician Information
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The pre-claim review request should include all documents from the medical record that supports medical necessity and all eligibility requirements for the beneficiary needing the applicable level of home health services.
We do not anticipate the entire record will need to be submitted to support medical necessity (e.g., not every PT note, wound care treatment, etc. may be needed.)
CMS Fact Sheet
Contact Name
Telephone Number
Submitter Information
Documentation Requirements
Medical record that supports the following:
Task #1 - Meets criteria for admissionUnder MD care
POC reviewed periodicallyNeeds skilled services
Nursing carePT/ST/OT
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Entering Documentation
Face to Face
Medicare does not require a new face-to-face encounter for additional episodes where the patient has not been discharged from home health care.
Documentation supporting the face-to-face encounter from the start of care should be submitted with the pre-claim review request for subsequent episodes of care
Face to Face
Face to Face encounter
Must have occurred no more than 90 days prior to SOC or within 30 days after
Must be related to the primary reason patient require home health services
Must be signed, dated with legible name and credentials or have signature attestation
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Signature Attestation
Make sure to have a signature attestation for any MD whose signature that may be considered slightly illegible or one who doesn’t have legible credentials.
Plan of Care
Yes, the plan of care needs to include the physician’s signature and date when it is submitted with the pre-claim review
request.
Entering Documentation
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Homebound StatusCriteria needed to meet Homebound Status Requirement
Criteria ONE of TWOComponents A or B
A – Requires the assistance of supportive device, special transportation or another person to leave home
B – leaving the home is medically contraindicated
Homebound Status
Criteria needed to meet Homebound Status Requirement
Criteria TWO of TWOMust have both Components A AND B metA – there exists a normal inability to leave
homeANDB – Leaving the home requires a considerable
taxing effort
Homebound Status Do’s and Don’ts
DO – describe with patient specifics
DON’T – repeat what criteria states
DO – fill out all Criteria needed
DON’T – use one word answers
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Homebound Criteria 1 Entry
Homebound Criteria 2 -(Don't enter the same file)
Homebound Criteria 2 Entry
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Adding Files
Miscellaneous Information
è Initial or Resubmission review
è State where services rendered
Benefit Period
è SOC
è ROC
è RECERT
è Change in POC
è Addition of discipline
è ALL of these require a PCR
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CMS PCR Overview
You should send your pre-claim review request to the same Medicare Administrative Contractor where you submit your home health claims
Methods of SubmittingeServices – the preferred method Electronic Submission of Medical Documentation (esMD)Go to www.cms.gov/esMD
MailPalmetto GBA- JM HH Pre-Claim Review
P.O Box 100234Columbia, SC 29202-3234
Fax803-419-3263
Methods of Submitting
è myCGSè Electronic Submission of Medical Documentation
(esMD)è Go to www.cms.gov/esMDè Mailè CGS Administrators
P.O Box 20203Nashville, TN 37202
è Faxè 615-664-5950
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Benefits of E-Service Submission
èEasiest way to submit
èFastest way to receive a decision
èReceipt sent when received
è Some info will pre-populate
Submission Requirementsè Attachments must be in pdf. Format
è Request will generate a Document Control Number (DCN)
è Attach individual attachments for each Task requested
è Error message will occur if an attachment has a duplicate name
è Naming several submissions as “Face To Face” for different patients
Website
èAvailable now but Texas does not submit yet
èKeywords : palmetto GBA eservices
èhttps://www.onlineproviderservices.com/ecx_improvev2/
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SubmittingèWebsite will walk you thru fieldsèAttach individual documents for each Task and not
just one for all Tasksè Just submit same document if on one page and
rename itèBe sure all uploads are in pdf. FormatèEach “Dynamic Tree” Tasks will have a tab to
upload the corresponding documentsèF2FèMD documentationè Signed POC
Additional InformationSite will also ask for “Impairment Status”è Structuralè Speech
è Cardiovascular …. ect
è Functionalè Cardiovascular
è Digestive….ect
è Activityè Communication
è Mobility……ect
Additional Information
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Additional Information
Submitting by Mail or Fax
èFill out all fields
èPrint out request
èPlace request in front of the request and use separator pages for documentation
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Separator Page Headings
èTask #1èF2f Clinical Encounter NotesèTask #2èHHA Generated RecordsèTask #3èPlan of CareèTask #4èSigned and Dated Physicians Certifications
Separator Page Headings
è Task #5 Q4 / Q5è Documentation that meets Criteria 1 è Confined to the Home
è Task #5 Q6è Documentation that meets Criteria 2 / Aè Patients Inability to leave Home
è Task #5 Q7è Documentation that Meets Criteria 2 / Bè Considerable Taxing Effort to leave Home
First Page – Resubmission Only
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Separator Pages
Review Time Requirements
èContractors are required to make a decision and notify submitter within 10 business days (excluding Federal holidays)
èDecision will come back :
èProvisionally affirmative
èNon-affirmed
Decision
The decision is quicker if you use the eservice submission
The decision will contain a UTN (Unique Tracking Number)
The decision will arrive the same way it was receivedUnless you originally sent electronically and then sent by US postal – then you will receive it electronically
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Denial To Bill Secondary
èFollow the normal process
èIf the claim gets a “non-affirmed” (denial) – submit the non affirmed UTN on the claim for denial
èSubmit the denied claim to the secondary insurance
Modifiers
èa PCR is not required for claims billed with the GY modifier
èa PCR is required for claims billed with the GA modifier
èwaiver of liability statement on file
Medicare as Secondary Payor(MSP)
èWhen you seek PCR
èSubmit PCR request
èSubmit the claim to primary for consideration
èSubmit the MSP claim to Medicare with the provisionally affirmed UTN for payment
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Medicare as Secondary Payor(MSP)
èMSP when you don’t seek PCR
èSubmit claim to primary insurance for payment consideration
èSubmit the MSP claim to Medicare for payment consideration and that claim will stop for pre-payment review
Provisional Affirmative Decision
èThis decision is a preliminary finding that a future claim submitted to Medicare for the services likely meets Medicare's coverage, coding and payment requirements
èIt will include :èThe UTNèThe HCPCS codes affirmedèDetails on those requirements not met
Non Affirmed HCPCS Codes
èTwo options :èSubmit the claim and the affirmed HCPCS codes will approve for payment and the non affirmed HCPCS codes will deny (and you can appeal)
èRe-submit the PCR for the non affirmed HCPCS codes which would result in a new UTN (based on that decision) and than use this for the final claim
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Non Affirmative Decision
èDocumentation does not meet one or more Medicare requirements
èThe notification will include
èThe non-affirmed UTN
èWhich HCPCS codes were non-affirmed
Incomplete DecisionèIndicates required information was missing
èThis notification will include an explanation of what was missing
èThis incomplete does not count as a submission – it essentially deletes it and the next time it is sent is considered an “initial” submission
Re-submitting
èDone for non-affirmative decisionsèProcess is same as initial èExcept identify it as a re-submissionèThere is no limit on the number of times the PCR can be resubmitted
èUnless the episode has endedèAlways select “Resubmission” on requestèAlways provide the most recent UTN
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Re-Submission Review time
èThe contractors have an additional 20 business days (excluding Federal Holidays) of the date received to make a decision and to notify the requester of the decision
èA notification :
èwill be sent for each request
èwill be sent to the beneficiary
Pre Claim Review Staff
èThe pre-claim review is administered by the Medicare Administrative Contractors (MACs)
èthe same contractors that currently process claims and conduct medical review on home health services.
èClinical staff are assigned to medical review and trained to ensure consistency.
Submitting The Final Claim
èAll data on claim is requiredèThe TOB (type of bill) is 329èEnter the 14 digit alpha numeric UTN provided in
the PCR requestè In electronic claims the UTN will follow the
Treatment Authorization Code (TAC) – which will remain in positions 1-18
èKey the UTN in positions 19-32 of loop 2300 REF02
èDo not use a space between TAC and UTN
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Submitting The Final Claim (cont)
UB04 Claim Form :The UTN will follow the TAC code in positions 1-18In positions 19-32 of field locator 63, key in the UTN
DIRECT DATA ENTRY : Page 5Enter 18 digit TAC in “TREAT.AUTH CODE” fieldOnce the TAC is entered the next field is where the UTN will be entered
Submitting The Final Claim (cont)
èYes. The Home Health Agency needs to wait until they receive the decision letter. The decision letter will contain a unique tracking number that will need to be submitted on the claim.
èSo, yes, you may provide a whole episode of care prior to review !
Submitting The Final Claim (cont)
èA pre-claim review decision is based on each episode of care. If a separate claim will be filed, a new pre-claim decision must be requested.
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Payment
IFall requirements are met
ANDA provisionally affirmative decision was issued
THENPayment will be made on the claim
BUT……Claims are subject to processing edits
Non Affirmed Decisions
è If a decision was non affirmed
èMedicare will not pay
èThis will constitute an initial payment
èStandard claims appeals process will apply
Non Affirmed Decisionsè The decision letter will specify why a Home Health
Agency’s (HHA’s) pre-claim review request was non-affirmed.
è The agency can correct the deficiencies and resubmit the request with a new coversheet and relevant documentation.
è If the agency does not wish to resubmit the request, it can submit claims with the unique tracking number identified on the non- affirmed decision letter.
è The claims will be denied, and the HHA can appeal the denial.
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Consequences of not doing a PCRè The claim will automatically be held for pre-payment
review
è You will get paid if all criteria are met
è You can appeal if denied
è If the claim is paid it will be reduced by 25%è Which CANNOT be appealed
AND….how do they determine if they pay you ?????
Consequences of not doing a PCR
BY AN AUTOMATIC Additional
Documentation Request (ADR)!!!
Consequences of not doing a PCRèCMS contractors may conduct targeted prepayment
and post-payment reviews to ensure that claims are accompanied by documentation not required or available during the pre-claim review process.
è In addition, the CMS Comprehensive Error Rate Testing (CERT) program reviews a stratified, random sample of claims annually to identify and measure improper payments.
è SOOOO….It is possible for a home health claim that is subject to pre-claim review to fall within the sample.
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Appeals
èThe standard appeals process applies to the final claim
èThere is no appeal process for a non affirmative PCR
èThat would be considered a “resubmission”
Appeal Process
èThe final claim should be submitted with the non affirmed UTN
èThat will result in a denialèThen the agency can appeal**If the final claim is submitted after the PCR without the UTN it will not process advising that the UTN is needed on the claim
Take Away
èTexas does not have to start submitting until at least January 1, 2017
èThere will be no penalty in the first 3 months
èIf you don’t submit you will lose 25% with NO appeal allowed
èNon submissions will result in an ADR
èOnline submissions are the best route
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Questions and AnswersI am a branch office located and providing services in a demonstration state, but my parent corporation is located in a non-demonstration state. You are included in the demonstration.
I am a parent corporation located and providing services in a demonstration state, but some of my branch offices are located in non-demonstration states. You and your branch offices providing services in the demonstration states would be included in the demonstration, but the branch offices located outside the demonstration states would not need to request pre-claim review.
Questions and AnswersI am a Home Health Agency located and providing services in a demonstration state, but also provide services to beneficiaries in a neighboring non-demonstration state.
You would be included in the demonstration only for services provided to beneficiaries in the demonstration state. You would not need to request pre-claim review for services provided to beneficiaries in non-demonstration states.
I am a Home Health Agency located in a non-demonstration state. I provide services to beneficiaries in both demonstration and non-demonstration states.
You would not be included in the demonstration.
Questions and AnswersI am a Home Health Agency located in a non-demonstration state that provides services only to beneficiaries that live in a demonstration state.
You would not be included in the demonstration.
Is pre-claim review needed for beneficiaries in the states already receiving home health services before the demonstration’s start dates?
Home health services provided to beneficiaries after the start date of the demonstration in their state will be subject to pre-claim review
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Questions and AnswersIf a home health claim is denied after receiving a non-affirmative pre-claim review decision, will the Request for Anticipated Payment (RAP) be recouped as an overpayment?
The Medicare Administrative Contractors will follow their standard procedures to recoup a RAP for any denied claims
Questions and Answers
Will beneficiaries have to pay for services if a Home Health Agency provides care but ultimately does not obtain a provisional affirmed decision?
Questions and Answersè In accordance with CMS polices, if an ABN was not
issued when required at the start of care and the pre-claim review is non-affirmative, the beneficiary is not financially liable for the care that the HHA provided while awaiting the pre-claim review decision.
è If the HHA believes that the pre-claim review will be non-affirmative for any of the reasons listed, the provider may issue an ABN in accordance with CMS policy which would allow the beneficiary to choose to receive the service and accept financial liability.
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Questions and Answers
è The ABN would be effective for denied services furnished after receipt of the ABN. If the HHA expects Medicare to cover the services, an ABN should not be issued.
è Blanket or routine issuance of ABNs is prohibited under Medicare policy.
Questions and Answers
50.2.2 Compliance with limitation on liability provisions:
a notifier who gave defective notice may not claim that s/he did not know or could not reasonably have been expected to know that Medicare would not make payment as the issuance of the notice (albeit defective) is clear evidence of knowledge.
The End
