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Are You Freaking Out About Pre-Claim Review? Are You Wondering How To Get The Docs On Board With Your Timeframes? You are Not Alone, But Don’t Be Afraid. Prepare Them Now!

stressed doctorMost agencies know the Review Choice Demonstration to be the new Pre-Claim Review. In order to make things flow smoothly, have all your ducks in a row first. However, you may feel getting your documents back from the MD may be impossible.  If so, let’s look at ways to ease the burden.

4 Ways To Streamline Your Pre-Claim Review Process:

If you do not have your act together internally, then it becomes tough to make it flow to others. Let’s look at 4 ways you can improve the process now so you are ready.

  • Tighten Your Own Timeline: Nothing is more frustrating to the docs then for you to push your timeline out to the very end and expect them to jump to your every need.  How long from admission to printed 485? How long until your face-to-face documentation is in place?
  • Look At Your Documentation Policies: Pre-claim may mean you need to change your workflow.  Are any steps unnecessary? Have you accounted for absences of clinical staff or coders? Pre-claim will absolutely hurt cash flow if you do not prepare properly.  If you complete in-house coding, have an outsourced provider contracted to prevent any gap in billing related to surge or absences.
  • Educate All Staff Involved In Process: As administrators, sometimes you struggle with how much information staff need to do a quality job. Ultimately, as home health spending increases, so has its scrutiny. Medicare must make sure that those providing care are doing so in the way CMS intended. Educate staff to know this is not a punishment from Medicare. Auditing has shown that many claims are paid improperly. CMS is trying to control money going out that shouldn’t.
  • Talk To Your Docs: Ultimately, they are going through auditing themselves. They are also dealing with every kind of provider with their respective audits and reviews. It is a lot. Recently, a physician approached me and stated, “I don’t care about this face-to-face stuff, but I have to do it”. No truer words have been said. Make the education simple. When we look back to face-to-face, it was extremely frustrating for everyone. Now, most agencies have a system that makes things easier for everyone.  Timeframe is the struggle. Illinois providers report better follow through and efficiency than before pre-claim review. So, it can improve.

So, How Do We Get What We Need For Pre-Claim Review:

Start with internal operations. Go to the docs with a system in place that makes things run as smoothly as possible. If you have docs that want to do things differently to help workflow, then do it. It will make the difference in your cash flow, turnover time, and ultimately, the satisfaction of your home care partners.  Don’t wait until you have a date on a calendar of go-time from CMS. Start now to alleviate pressure for everyone.

Let Us Help You Make Things Easier:

At Kenyon Homecare Consulting, we have senior consultants who have been through years of different auditing processes. Call us today at 206-721-5091 or contact us online for your free 30 minute consultation.

The Future Of Homecare Lies With Pre-Claim Review. Make Sure You Are Ready To Face it Full Steam Ahead!

In 2016, Illinois was hit with pre-claim review.  Yikes.  The rest of the nation bristled at the thought. Now, multiple states are in the 5 year Review Choice Demonstration.  It may be a different name, but it is the same concept. Let’s look at who is involved and why all states need to pay attention.

Why Illinois, Ohio, North Carolina, Texas, and Florida?:

Pre-Claim ReviewWell, CMS determined these areas to have known fraud.  It is known fraud and/or high denial rates in previous probe and educate rounds that put these states on the map.  What CMS learned from the 2016 demonstration was that it was able to save money.  So, it only makes sense from that end to continue with a pre-claim process.  December of 2018 will begin the Review Choice Demonstration (RCD) with Illinois and other states will come thereafter.

3 Options For RCD:

Option 1 is just what Illinois did in 2016 where 100% of claims are submitted for pre-claim review.  Option 2 is strictly a post-claim review.  This means 100% of charts will have full ADRs prior to payment.  If you choose not to submit at all, then option 3 allows agencies to receive all Medicare payments with an automatic 25% reduction of payment.  It also sets agencies up with a big target for RAC audits.  After 6 months of review, agencies have either 5% of claims every 6 months for pre-claim review or there will be selective post-payment review.

It will be important for agencies to maintain high levels of compliance in the subsequent 6 month periods.  At any time an agency can be thrown back into 100% pre-claim if compliance is not maintained in every 6 month spot checks.

Will This Happen To All States?:

If CMS yields the same results as the 2016 demonstration, then there is no reason to believe this will not be an ongoing reality for everyone moving forward.  So, what makes sense is to prepare your states for improved turnover time in documentation to prevent RCD from hurting cash flow.  If you address the process with physicians, then it will help with turnover time for orders. With agencies already struggling with cash flow in many states, the industry cannot afford delays in payments.  Know what cash reserves you have to prepare for delayed receipt of payment.

Let Us Help With Your Processes:

With an organizational assessment, Kenyon Homecare Consulting can help tighten your internal processes to prepare for RCD delays. If you would like to discuss how we can help prepare you for RCD, call us at 206-721-5091 or contact us online today.

ADR Denials? Do You Know Why? How To Make Your Agency The Gold Standard And Never Lose Reimbursement Ever Again!

ADRAudits are a part of everyday life in the healthcare world today.  You may be a home care agency that is really tired of receiving ADRs and think they won’t stop. Well, let’s talk about how to make sure you don’t end up with a lot more than you should.

4 Ways To Make The Process A Whole Lot Easier:

There are many ways that agencies can find themselves in a field of denials and not know how to change it.  If you look at these four things, then you should be able to protect yourself from additional denials and loss of reimbursement.

  • Make It As Easy As Possible For The Reviewer: The people your intermediary has hired to complete the auditing are human just like everyone else. Understand that they miss things that may be in the submission. Send things in the exact order listed on the ADR. Often times a cover letter in front of the chart will paint the picture of patient needs before the auditor ever gets into the record.
  • Highlight What The Auditor Should See: This is especially pertinent with Face-To Face. Highlight where each item is addressed that complies with the regulation. If you have 3 different items that contain all the documentation you need, put a sheet in that designates what makes up your Face-To-Face.  If not, you run the risk of the auditor using just the physician visit. This may not contain your homebound status or another item specific to the coverage.
  • Send Them Electronically: Regardless of your intermediary, it is quicker and easier electronically. The last to be reveiwed are the items sent by regular mail. You run the risk of the documents not being there on time. These are the last of the ADRs to be reviewed. This potentially causes your agency a cash flow issue.
  • Standardize Your Agency Process For ADRs: If you are an agency with multiple branches, then make sure everyone submits to you the same way. Just like the auditor, when you prepare the documents to submit, the chart needs to make sense. If you can’t decipher where the items are, then neither can the auditor. They will not take additional time searching for everything. You don’t have the time either. So, standardize how the documentation comes to you too.

Appeal, Appeal, Appeal!:

As previously stated, the auditors are human and miss things too. Many times, you may even have things highlighted and the denial may say the item is missing.  Too many agenies do not appeal their ADRs. This means more for you and everyone else. Unless there is truly a problem with compliance, you should always fight for the reimbursement. If this means going to the Administrative Law Judge, then do it.

Let Us Help Decrease Your Risk And Refine Your Process:

At Kenyon Homecare Consulting, we have senior consultants with years of experience dealing with the auditing process.  We can help educate those responsible, help make sure your process is effective, and help do them for you in times of surge.  Call us at 206-721-5091 or contact us online if you need some help.