What Changing Medicare Pre-Claim Reviews Mean For You

The Centers for Medicare and Medicaid Services (CMS) have once again proposed a change to pre-claim reviews and demonstrations. This change will not affect every state, only Ohio, North Carolina, Florida, and Texas at this time. However, all states need to be prepared for whatever is ultimately decided, as CMS has already stated that they reserve the right to expand the new process to other states as they see fit.

Why the review process for home health services is changing.

According to the Federal Register, CMS believes that “revised demonstration would help assist in developing improved procedures for the identification, investigation, and prosecution of potential Medicare fraud. The demonstration would help make sure that payments for home health services are appropriate through either pre-claim or post-payment review, thereby working towards the prevention and identification of potential fraud, waste, and abuse; the protection of Medicare Trust Funds from improper payments; and the reduction of Medicare appeals.”

Home health service agencies who do not wish to participate in 100% pre-claim or post-payment review by CMS run the risk of seeing their Medicare reimbursement drop 25%. Given the generally-poor reimbursement of Medicare services to start, this additional reduction may very well spell disaster for those agencies that are not prepared well in advance of the program’s rollout.

What can providers do to expedite reimbursement under the new pre-claims review guidelines?

Unfortunately, for providers, these changes will inevitably add additional steps to the Medicare claim process as well as extend the timeframe within which they will be reimbursed. However, as always, knowledge is power, and having an understanding of what will be required by CMS in order to push claims through in a timely manner in this new, tougher environment — ahead of the changes being rolled out — may very well be what makes or breaks a home healthcare agency.

As you might imagine, there is no “secret sauce” that will suddenly ensure expedited reimbursement for every claim. The only sure-fire way to keep claims processing as smoothly as possible in any healthcare setting is to submit a truly “clean” claim in the first place. While clean claims require more work on the front end, they almost always more than make up for it on the back end in the form of faster processing, usually the first time around (rather than the second, third, or even fourth), leading to quicker reimbursement for providers. This is a subject we’ll tackle in more detail next week, but here’s a preview — a primary component of a clean claim is documentation, documentation and more documentation.

How Via can help home health services providers get paid faster.

Even the cleanest claims paired with the most experienced insurance specialists can only do so much to expedite processing through the complicated maze that is Medicare. This is why many companies have chosen to integrate Aquina’s Via solution into their claims processing system. Via allows insurance claim reimbursements to be expedited, ultimately contributing to the smooth, continuous flow of revenue that keeps home health service agencies’ bottom line strong. With integration already in place with leading EHR providers such as athenahealth and Kareo, getting started is easy. Contact Aquina Health today and find out how.