Kenyon HomeCare ConsultingThe Future Of Homecare Lies With Pre-Claim Review. Make Sure You Are Ready To Face it Full Steam Ahead! - Kenyon HomeCare Consulting (206) 721-5091

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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.

Category: ADRs, Regulatory Compliance

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