April 1, 2017, is rapidly approaching, which means home health agencies in Florida are gearing up to implement the new CMS mandate for Pre-Claim Review Demonstration (PCRD). If you’re like most agencies, you’re probably nervous about how this change will impact your organization and how to ensure a smooth transition for everyone involved.
We’ve outlined what you need to know about PCRD, how it affects your agency, and what you can learn from agencies in Illinois who are already using Pre-Claim Review.
What Is the Pre-Claim Review Demonstration (PCRD)?
Pre-Claim Review is a review process managed by Medicare Administrative Contractors (MACs) before a final reimbursement. It’s designed to help ensure that applicable coverage, payment, and coding rules are met before a final claim is submitted. By enacting this program, CMS hopes to reduce fraud while improving the quality of care to Medicare beneficiaries.
Notably, Pre-Claim Review requires the same documentation as before – except now it’s submitted earlier in the process. Agencies can adapt to the new system by ensuring they have simple and automated document management practices in place.
PCRD is already in place in Illinois and is set to go into effect in Florida beginning April 1, 2017. PCRD will also eventually be implemented in Texas, Michigan, and Massachusetts.
Important Lessons from Illinois Agencies
With the looming transition, Florida agencies are looking to Illinois for guidance, where the program had a bumpy start. Indeed, many agencies found themselves on a steep learning curve to have their pre-claim submissions affirmed.
Several lessons can be gleaned from this experience:
1. Provide Consistent and Specific Documentation
One of the biggest PCRD-related complaints from agencies in Illinois was non-affirmation results on an inconsistent basis. While the reasons for non-affirmation rates can vary greatly, generally the more specific the documentation, the faster pre-claims are affirmed.
2. Get Your Management Team on Board
PCRD will likely be a major change to the way you process claims. The clinical staff who handle the documentation and your leadership both need to be on board to facilitate the transition. With a potential threat to reimbursement rates, compliance must start at the management level of your organization.
3. Educate Everyone Involved (Including Physicians)
Not everyone affected by PCRD will have the same understanding of the requirements and new processes. To ensure a seamless implementation, make sure everyone understands what pre-claim review is, how to implement it, and what is expected of them.
This means educating everyone involved – including your administrative team, office staff, field staff, physicians, referral sources, and even patients. Try sending internal email newsletters, holding group education sessions with staff members, talking to physicians about requirements, and letting patients know about upcoming changes.
4. Have the Right Staffing Structure in Place
In Illinois, submitting the required Pre-Claim Review documents typically took longer than CMS estimated; in some cases, it took up to an hour. Because of this, some Illinois agencies hired a full-time employee to keep up with the PCRD requirements, while other agencies achieved success by reorganizing their staffing structure.
How Agencies Can Prepare for PCRD
One of the best things agencies can do to ensure a smooth transition to PCRD is to review current document management processes. A full list of required documents can be found on pages eight and nine of the Pre-Claim Review Demonstration for Home Health Services Operational Guide from CMS. Organized and efficient workflows paired with strict follow-up procedures for all processes will be critical.
Remember: Your agency’s people, processes, and technology are critical to a successful and seamless implementation of Pre-Claim Review. If you haven’t already, it’s important that you educate your team, determine who will be doing what, and implement tools that can help streamline the process.
At CellTrak, we have the knowledge and experience needed to help home health organizations drive more efficient documentation processes. To learn more about how we can help your agency, contact us today.
