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Delta Connect Blog

Is Pre-Claim Review Coming Back?

Posted by Crystal Parks on May 31, 2018 9:10:18 AM


CMS plans to bring back an altered version of the Pre-Claim Review (PCR) demonstration that was halted at the end of March 2017.  The May 29 offer for public comment by CMS revealed that the PCR demonstration found paperwork errors instead of the fraud that it was intended to uncover. 

This newer version of PCR would compel providers in demonstration states - which vary from the original demonstration states - to submit all claims for review either before or after payment has been made or suffer a 25% cut in payment. In addition, providers that do not submit claims could be subject to Recovery Audit Contractor reviews. The original version of PCR did not have a post-payment review option.

“These providers will continue to be subject to a review method until the HHA reaches the target affirmation or claim approval rate,” CMS-log-blue according to the notice. “Once an HHA reaches the target Pre-Claim Review affirmation or post-payment review claim approval rate, it may choose to be relieved from claim reviews, except for a spot check of their claims to ensure continued compliance.”

The CMS proposal comes hot on the heels of a Government Accountability Office (GAO) recommendation that the agency bring back the PCR demonstration. 

CMS proposes to run the new PCR demonstration in Florida, North Carolina, Ohio, Texas, and Illinois, the only state to have experienced the original PCR demonstration. Florida and Texas were states targeted for the original PCR, but the demonstration was halted before it began there. North Carolina and Ohio are new states added to the list of possible PCR targets. CMS holds open the possibility of expanding this newer version of PCR to other states beyond those named in the notice.

The public has 60 days to comment on the CMS proposal once it is officially published in the Federal Register.

While the post-payment review addition to the demonstration might ease some of the problems with cash flow caused by the original iteration of PCR, it is very likely to lead to a substantial appeals backlog, as providers appeal denials by Medicare Administrative Contractors. In the original version of PCR, many denials were found to be based on simple and innocent paperwork errors.

It is important to remember that when PCR was halted originally it did NOT find evidence of unnecessary care or services provided that were not meant to be covered. Instead, PCR merely found correctable documentation issues, a problem that was fixed and was hardly worth the pain inflicted on home health providers and patients.

If PCR, at least in its original form, was created to root out fraud and abuse, it was poorly designed. The Office of Inspector General (OIG) has identified characteristics commonly found in fraud cases, so CMS should concentrate its resources on pursuing those outliers, instead of punishing hard-working and law-abiding home health agencies and their patients.

Topics: Pre-Claim Review


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