Title Slide
Today s educa%onal presenta%on is provided by The so1ware that powers HOME HEALTH. THERAPY. PRIVATE DUTY. HOSPICE
At Kinnser, we believe post-acute care businesses need the right so5ware solu9on for today and the right technology partner for tomorrow. 20% of our annual revenue goes toward Research & Development
Request a demo of the Kinnser soluoons that will help your agency succeed kinnser.com/requestademo 877.399.6538 sales@kinnser.com www.kinnser.com
About the presenter SHARON S. HARDER President C3 Advisors, LLC
What Agencies Should Know THE BASICS OF PRE-CLAIM REVIEW
WHO will be affected by Pre-Claim Review? What is Pre-Claim Review? When does Pre-Claim Review Start? How will Pre-Claim Review work? UNDERSTANDING THE BASICS The Who, What, When and How of the Pre-Claim Review Program
What is PCR? PCR is a 3-year demonstra%on project. PCR has been designed to thwart fraud and prevent improper payments. Which agencies will be affected by PCR? PCR is focused on 5 high risk states, including: Illinois Florida Texas Michigan Massachuse\s PCR par%cipa%on is voluntary, but failure to take part will carry a steep price.
Understanding the Basics When will PCR become effecove? PCR starts with Medicare FFS episodes beginning on or a1er Aug 1 in IL FL, TX, MI and MA are scheduled to follow Dates are tenta%ve for FL, TX, MI and MA and could be adjusted FL current schedule is Oct 1 TX current schedule is Dec 1 MI and MA current schedule is Jan 1
Understanding the Basics How will PCR work? PCR request is submi\ed to the MAC a1er the episode begins and before the final claim is sent. PCR requests will be accompanied by key documenta%on that will enable the MAC to make a decision. Provisional Affirma%on Non-Affirma%on Addi%onal post-payment reviews CERT, MAC & ZPIC
PCR DocumentaOon Basics! There is no set list of documents that must be submi\ed. Face to Face Encounter documenta%on Plan of Care Eligibility Cer%fica%on Informa%on to support Homebound Status and Medical Necessity
When is it necessary to submit a PCR request? Before the final claim for: Starts of Care Recer%fica%ons Excep%ons for LUPAs Transfers to a new HHA Discharge and readmit within the same 60-day period
Unique Transac9on Numbers A Unique Transac%on Number (UTN) will be assigned to every PCR decision. UTNs must appear on submi\ed final claims and the claim payment will coincide with the PCR decision. UTNs will follow the Treatment Authoriza%on Code that is generated from the OASIS.
HCPCS Will Be Important! Every PCR request will need to include the HCPCS that are an%cipated based on the orders.! When Provisional-Affirma%on decisions are reached, the UTN will be %ed to the preliminarily approved HCPCS.! Fiscal Intermediary Standard System FISS limita%ons and poten%al PCR issues around HCPCS.
HCPCS Covered by PCR HCPCS Code Discipline/Svc Type HCPCS Code Discipline/Svc Type G0151 Physical Therapy G0299 RN Direct Skilled Services G0159 PT Maintenance G0300 LPN Direct Skilled Services G0157 PT Assistant G0162 RN Mgmt & Eval of POC G0152 Occupa%onal Therapy G0163 SN for Observa%on/Assessment G0160 OT Maintenance G0164 SN Training of Pa%ent/Caregiver G0158 OT Assistant COTA G0155 Medical Social Worker Services G0153 Speech Language Pathology G1056 Home Health Aide Services G0161 SLP Maintenance
Split Decisions Affirma%on of some services HCPCS and not others based on determina%ons of medical necessity This is why submission of all of the documenta%on required for approval will be important Therapy evals and orders not in the Plan of Care Local Coverage Determina%ons
Resubmissions In the event of a non-affirma%ve decision, the PCR request can be resubmi\ed an unlimited number of %mes. BUT there are lots of reasons to get it right the first %me! Staff impact of having to repeat the work Cash flow impact of claim payment delays RAP auto-cancella%ons and Palme\o RAP suppression exposure
The First Three Months Final claims without a pre-claim review and UTN will generate an ADR. No payment reduc%on during the first three months. A1er three months, claims without the prior PCR will generate ADRs and will have a 25% payment reduc%on upon approval.
What about RAPS? Nothing changes RAPs can and should be submi\ed as usual A cau%onary word about RAP suppression exposure Circumstances when it may be wise to delay the RAP
Inten9onal Delays of Care Unintended Consequences CMS has made it clear that pa%ents who are accepted for service must be served in accordance with the %melines in the Plan of Care. CMS evalua%on contractor will monitor for fraud and incidents where the agency inten%onally delayed services un%l a1er receiving the PCR provisional affirma%on decision.
Probe and Educate Good news! The Probe and Educate ini%a%ve is being tabled as the PCR demonstra%on project is implemented. Applies only to the five states
Appeals Handling non-affirma%ve PCR decisions through the appeals process Provide and document the services Submit the final claim Once a denial is received, submit the redetermina%on request to the MAC
What Agencies Should Do HOW TO PREPARE FOR AND CONQUER PRE-CLAIM REVIEW
Get Organized! Process Considera9ons Do your agency s processes need to be refined? Documenta9on Considera9ons Does your agency s documenta%on paint a complete and unified picture of the pa%ent? External Cons9tuencies Do your physicians understand the implica%ons of PCR? Timing Considera9ons Does your agency acquire documenta%on in a %mely manner? Revenue Cycle Considera9ons Have you planned for delayed cash flow as a result of PCR?
Turn DocumentaOon Around More Quickly Acquire F2F Encounter Informa%on at Referral DAY 1 Iden%fy F2F Encounter Gaps DAY 1 Finalize the Comprehensive Assessment DAY 2 Excerpts to Fill F2F Gaps DAY 3 Plan of Care DAY 3 Plan of Care & Other Documenta%on to the Physician DAY 4 PCR Request DAY 30
The Intake & Recer9fica9on Processes Do Your Processes Need to Change? Making the decision to admit or recer%fy KEY QUESTIONS Is this pa%ent homebound? Does this pa%ent have a skilled medical need that is related to Face-to-Face encounter informa%on? Is this pa%ent under the care of a physician who will follow for home health? Can the agency provide the services that are required and have a reasonable expecta%on of being able to document those services to support an affirma%ve PCR decision?
Documents Must Be Unified and Consistent There must be a firm and unified rela%onship among the key elements of the record. Admission informa%on The Comprehensive Assessment The Plan of Care Face-to-Face Encounter informa%on
The Comprehensive Assessment Confirma%on of skilled need, findings in support of homebound status and overall eligibility? Rela%onship between assessment findings and the Plan of Care disciplines, visit frequencies, interven%ons and goals? Rela%ng the assessment findings in support of homebound status to the physician encounter. Are the bases covered?
The Plan of Care Are the disciplines and visit frequencies reasonable in light of the pa%ent s diagnoses? Are the interven%ons reasonable in terms of the visits planned? Does the POC contain informa%on that supports applicable LCDs? Are the goals clear and measureable? What HCPCS will be used to fulfill the care plan?
Face-to-Face Encounters Gewng the Face-to-Face Encounter physician progress note or DC Summary is first and foremost Does the physician or facility record confirm homebound status, medical necessity and presence of a physician who will oversee care? Does the agency need to add informa%on to the F2F encounter record to underscore eligibility? Does the informa%on from the assessment corroborate the physician or facility record?
Organizing the PCR Submission Understand when less is more. Consider developing a form for each episode with the basic required informa%on. Make sure that submission documenta%on is complete. Put the most important documents first.
Required PaOent, Physician and Agency InformaOon 1. Beneficiary Name 8. Home Health Agency Name 2. Beneficiary Medicare Number 9. Home Health Agency NPI 3. Beneficiary Date of Birth 10. CMS Cer%fica%on Number 4. Cer%fying Physician Name 11. Agency PTAN (op%onal) 5. Physician NPI 12. Agency Address, City, State, Zip Code 6. Physician PTAN (op%onal) 13. Agency Contact Name 7. Physician Address, City, State, Zip Code 14. Agency Contact Telephone Number
Other Submission InformaOon The type of benefit period Ini%al/SOC or Recer%fica%on Submission date From and through dates for the episode under review The type of PCR request Ini%al or Resubmission State where the services were provided
Submi[ng the Pre-Claim Review Request Four basic op%ons: 1. For Palme\o e-services and for CGS - mycgs 2. Website form 3. Mail goes to a PO Box, so no FedEx or UPS 4. Fax The best op9on is clearly the electronic route. The op9on that the agency starts with will apply through the remainder of the process for each episode.
E-services Documenta%on that addresses each requirement is scanned and a\ached to the task document request. This is not one big document, but several smaller ones. Document names must be different as each document can only be a\ached once. Consider an agency specific document naming conven%on by task. Before the submission is completed, the user will be alerted to errors and/or omissions.
E-services Submi\al Requests Step 1: Go to the e-services portal and log in Step 2: Select the Pre-Claim Review tab and the type of review Step 3: Enter the Provider, Beneficiary and Claim informa%on (Start Date, End Date, TOB, and HCPCS Codes) Step 4: Validate the beneficiary informa%on Step 5: Complete the Dynamic Tree segments
e-services Dynamic Tree Q1: Was the beneficiary admi\ed to your home health agency directly from an acute or post-acute facility? Q2: Was the home health cer%fica%on and F2F encounter performed by the same physician? Task 1 - Upload the F2F Encounter note using the Browse Bu8on. Q3: Do you have any HHA generated records (i.e. pa%ent s comprehensive assessment) that have been signed, dated and incorporated into the cer%fying physician s medical records? Task 2 - Upload the HHA records that have been incorporated into the physician s record. Task 3 - Upload the signed/dated POC. Task 4 - Upload the signed/dated cerdficadon of eligibility.
Dynamic Tree (con%nued) Q4: Confined to the home first criteria. Does the beneficiary because of illness need a suppor%ve device, special transporta%on or assistance of another to leave home? Task 5 Upload medical documentadon that meets the First Criteria for Confined to the Home. Q5(6): Confined to the home second criteria. Is there a normal inability to leave home? Task 6 Upload medical documentadon to support the normal inability to leave the home. Q6(7): Does leaving the home require a considerable and taxing effort? Task 7 Upload the documentadon to support the considerable and taxing effort.
Dynamic Tree (con%nued) Q7(8): Is there a structural impairment? Q8(9): Is there a func%onal impairment?
Dynamic Tree (con%nued) Q9(10): Is there an ac%vity limita%on? One final note: For resubmissions, the UTN associated with the first or prior submission will be required and resubmissions will require submission of all documenta%on again.
e-services Errors/Omissions
Conclusion With PCR, Timing Is Everything The Pre-Claim Review process will add a minimum of 10 extra days to agency claim submission %melines. That means cash flow delays which will affect the same 10-day period. If the agency is inefficient and experiences a pa\ern of having to resubmit to get an affirma%ve decision, the cash flow implica%ons will be even worse. It will be crucial to get required documenta%on in useable form from physicians and clinicians sooner. Agencies must make be\er admission and recer%fica%on decisions to ensure payment for services. Remember, the Condi%ons of Par%cipa%on s%ll apply.
At Kinnser, we believe great care and great business go hand in hand. 4,500 + Agency Customers 49% Faster DocumentaOon 27% More ProducOve 52% Faster Billing 33% Less Expense REQUEST A DEMO! kinnser.com/requestademo