An important update to the article we wrote below earlier: CMS has announced continuation of the program after a brief halt.  Read their statement on  roll out of pre-claim review. Read CMS’ official statement here.

CMS introduced a  new process that will affect Illinois, Florida, Texas, Michigan, and Massachusetts. Even if you aren’t in one of these states, it might be a good idea to read on and get some more info. The process has already become effective in Illinois and will go to Florida next. With some of the issues that Illinois agencies have faced with the process both Florida Senators have spoken out against the implementation of pre-claim review. In a letter to the Acting Administrator of CMS the two senators explained that “[they] remain concerned this demonstration may restrict beneficiary access to timely services, divert clinical resources to paperwork management, and incur high administrative costs,” and are pushing for the delay of implementation of the demonstration in Florida and other states until a proper assessment can be made of the impact of the methods.

What is Pre-Claim Review?

If you have come this far, it might be a good idea to get an explanation of what pre-claim review is. In theory, it isn’t any different than what you all are already submitting to CMS. It does however, require you to submit some of the information earlier in the cycle and drop it into a separate portal. CMS will then take that information and issue an authorization code if the claim has been reviewed. This happens BEFORE the claim is even submitted. So theoretically, nothing is changing, BUT, the additional steps and processing time can have some effects on the agency. You can check CMS’ site if you want more detailed info on the pre-claim review process.

What Happened in Illinois?

Simply put, A LOT. According to some sources it has been a total disaster. NAHC is saying that it has increased the paperwork portion of pushing a claim through by 40-50 times and are estimating that it takes about 1 hour of additional time just to prepare the documents to send for the pre-claim review. Not just that, but it appears that there has been serious issues with “lost” documents that were transmitted electronically. This has resulted in a lot of denials of the submission and is causing further problems. Many home healths have been forced to hire on extra people just to process the documents and some are even considering delaying start of care until AFTER CMS gives them the green light. The problems go on even further because agencies that receive denials are having a hard time communicating and understanding exactly why they received a denial. Basically, what in theory should have been no problem, has turned into a major burden on agencies and possibly care recipients alike.

What’s Being Done?

NAHC is working aggressively to mitigate the possible damage that the pre-claim review demonstration might do. They worked with the Florida senators to create the letter urging CMS to delay any further  implementation of the demonstration until an analysis of its impact could be completed. They are also working closely with providers in the states affected and are creating advocacy groups to push back on the issues the demonstration has caused. They may even initiate a lawsuit if further damage continues.

That’s all for now, but we will make sure to keep you posted on any other changes or updates that come up.

Our products are designed to help make the pre-claim review process as easy as possible. If you are a client in one of the pre-claim review sates, make sure you reach out to our training department and sign up. If you aren’t using a Data Soft Logic product, you should get in touch with us so we can show you how our software can help with the pre-claim review process and increase the efficiency of your agency.

Well keep our eyes and ears open and keep all of you updated accordingly.