By Altamash Mir
In its recent release of information pertaining to the Pre-Claim Audit, CMS has released an operational guide. This Operational Guide outlines on how the flow of documentation should be when submitting requests to MACs.
We have developed a form & a process flow chart which can be used by Home Health Agencies when submitting Pre-Claim Review Requests to their respective MACs (Medicare Administrative Contractors) scroll down
Here are some major things that all Home Health Agency Administrators must know:
• Pre-claim Authorization is needed for ALL New Patients (SOC’s) & any patients being Re-certified (Recerts) after the implementation date
• Any episodes of care beginning prior to the implementation date (August 1st, 2016 in IL) will need pre-claim authorization for the episode beginning after the implementation date, such as a Re-certification.
• Get ready for submitting requests early!!! Agencies could send pre-claim authorization requests two weeks prior to the implementation date.
• Agencies can send requests anytime between the SOC & the end of episode, but before submission of the final claim of that episode.
• Low Utilization Payment Adjustment (LUPA) episodes will not be subject to Pre-Claim Authorizations.
• Episodes that are less than 60-days will require a pre-claim review.
• Sign up for the online method of sending Pre-claim authorization requests (scroll down to get contact info for your MAC’s)
• Agencies CANNOT put patient care on hold, while waiting for Pre-claim authorization request decision! You are still held liable for a patient that has been admitted to your agency!
• The provisional approval (within 10 days) from your MAC is not transferable to another patient or agency.
• Utilize the form that we have developed to send your Pre-claim authorization requests (email to request)
Among some new requirements, CMS has outlined a few that will be completely necessary to fulfil while submitting requests for Pre-claim review:
1. Physician/Practitioner Signature on Plan of Care (Form 485)
The biggest hurdle that seems to be looming over everyone concerned is “Physician/Practitioner Signatures”.
As we all know and have gotten used to, Physicians are not so cooperative in providing much needed documentation in a timely fashion. Most of the times, the orders are faxed in late or face to face evaluations are missing crucial elements.
With the new changes in Home Health payment systems, Home Health Agencies are urged to speak with their patients and patient’s families and have them re-iterate to their Physicians the importance of timely & accurately completion of documentation. After all, Home Health Agencies will be dependent upon this documentation to be able to successfully provide quality Health Care to their patients.
2. Homebound Status
CMS has always required for any patients admitted under the Home Health Program to be homebound. As always they’ve reiterated the importance of this aspect and outlined the following conditions:
a. Patient must be Confined to Home (Homebound)
b. There exists a normal inability to leave the home and
Leaving home requires a considerable and taxing effort.
AND one of the following is true
c. a) Because of illness or injury, the person needs the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence; or
d. The person has a condition such that leaving his or her home is medically contraindicated.
3. Face to Face Evaluation
The Agency must have a Face to Face Encounter Documented by the Physician/Practitioner which should:
a) Occur no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care and
b) Be related to the primary reason the patient requires home health services; and was performed by a physician or non-physician practitioner
c) The certifying physician must also document the date of the encounter