CMS announced this week that its pre-claim review demonstration program will expand into Florida for episodes of care beginning on or after April 1, 2017. CMS did not announce start dates for the remaining three states (TX, MA, and MI) slated for pre-claim review expansion.
The roll-out of the project in Illinois on August 3, 2016 triggered confusion, significantly increased paperwork burdens, high volumes of claim rejections, and irrational claim determinations. CMS reported that in week 18 of the Illinois project, the affirmation rate of pre-claim review submissions had reached 87%. That rate includes submissions that were originally rejected, but later affirmed on resubmission.
CMS initiated the pre-claim review demonstration project to address the Comprehensive Error Rate Testing (CERT) findings that the “improper payment rate” for home health services had increased from 17 percent in 2013 to 59 percent in 2015. It is believed that the vast majority of the “improper payments” relate to issues with the physician certification and face-to-face documentation requirements.
The Illinois experience has had some positive outcomes. The most notable is that CMS has recognized that the complex task of claims reviews can lead to errors by its contractors. In recent weeks, home health agencies in Illinois have received review affirmations on the types of cases that previously had been rejected for insufficient documentation. In addition, home health agencies have recognized their own documentation weaknesses and have taken corrective actions. Hopefully the lessons learned by all parties in Illinois can inform CMS to use much less burdensome remedial actions than pre-claim reviews with comparable results.
CMS plans to expand the demonstration. However, some experts believe there's a possibility that the demonstration might end in 2017 with Republicans in control of Congress and the White House since Republican leadership has expressed serious concerns about the demonstration.