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Illinois' New Home Health Review Process Not Ready for 'Prime Time'
Posted on: 10/13/2016

ISMS has heard from many of our physician members about the Centers for Medicare and Medicaid Services' (CMS) new home health Pre-Claim Review Demonstration (PCRD) that rolled out in Illinois on Aug. 3, 2016.

Physicians are concerned that this policy change, expected to be in place over the next three years, may create additional administrative burdens and may ultimately jeopardize access to home health services for Medicare patients.

How it works is that Home Health Agencies (HHAs) in Illinois must now submit documentation to the Medicare Administrative Carrier for services provided to Medicare patients for a “pre-claim review.” In other words, rather than submitting documentation at the same time as a claim, the agencies are to provide complete documentation earlier in the process.

While the focus of PCRD is on reimbursement to the agencies, this process places new burdens on physicians who certify patients for home health services.

Since pre-claim reviews were implemented in early August, HHAs have experienced a 60 to 80 percent denial rate of pre-claim submissions. The agencies must then gather additional information and documentation – much of it from physicians.

Further, many of the denied claims have general “boiler plate” responses and offer no explanation or guidance from Medicare, which leaves patients and health care professionals with uncertainty as to what services will be covered.

Illinois was the first of five states that CMS planned for the demonstration, which is intended to close fraud and abuse loopholes associated with home health claims. Since it became obvious that PCRD was not yet ready for “prime time,” implementation for the four other states has been put on hold.

Illinois’ congressional delegation is aware of this flawed program. Read a bipartisan letter to CMS from Illinois’ federal lawmakers.

Illinois needs to preserve patient access to home health care services while maintaining quality care for seniors in the most cost-effective, medically appropriate setting.

We would like to hear from you about your experiences with PCRD. Please contact the ISMS Advocacy Team at 800-782-4767 ext. 1470 or send an email.

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