A Summary of Pre-Claim Review for Home Health Agencies

By now, home health agencies are well aware of the new program under development by CMS to crack down on what they believe is a major problem with improper payments for their services.  This is referred to as the “Pre-Claim Review Demonstration”.

This document describes these new regulations that were published in the Federal Register in June.

This effort is a drastic attempt by CMS to reduce the increasing improper payment rates associated directly with home health services.  Essentially, developing a process to examine 100% of all claims submitted by Home Health Agencies (HHA) prior to their approval and final payment.

Pre Claims Review for Home Health

CMS’s Comprehensive Error Rate Testing (CERT) program annually estimates the percentage of payments that did not meet Medicare coverage, coding and billing rules.  For 2015, they calculated the improper payment rate for home health claims at 59%.  This compares to 51.4% in 2014 and 17.3% in 2013.  CERT determined that a majority of errors that occurred in 2014 were due to the fact that the narrative documentation associated with face-to-face encounters did not support the patient’s homebound status and the need for skilled services.  Now CMS no longer requires separate narrative documentation for the face-to-face, but they are still seeing many cases where the documentation provided by the HHA in the medical record does not support the home health benefit they are providing.  These improper payments do not necessarily indicate fraud, it may simply be a lack of documentation, documentation errors, or a lack of understanding of Medicare rules.  However, fraud is a substantial contributor to the problem.

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The “Sticky” NOE Problem

MEDTranDirect is a vendor of Medicare connectivity services, including access to the CMS HETS system (HIPAA Eligibility Transaction System) that provides real time eligibility data for healthcare organizations.  The data processed through this system is intended to provide a complete picture of all beneficiary data necessary to determine if payment will be received when healthcare services are provided to Medicare patients.

Late last year, we found a problem in the HETS data where the hospice NOE (Notice of Election) data was only present part of the time when it was processed in the CWF (Common Working File).  We documented this issue and reported it to HETS support.  Their initial response was that this was not a claim and that is why it was not showing up.  This did not make much sense since it did show up at least half of the time.  We resubmitted the problem again in February of this year, their response at that time was that it did not show up because the data was not in the CWF and the problem was with the MACs processing the NOEs and not the HETS system.  This conclusion was also not supported by the data we provided since we gave them screenshots of NOEs entered and accepted in DDE (Direct Data Entry), but were not present in HETS several days later.

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Using Modems for Medicare Connectivity

MEDTranDirect provides connectivity between healthcare providers and all the Medicare contractors (MACs).  Through this connection, providers can have access to the Direct Data Entry (DDE) or FISS system, the ability to send claim files and receive response files like the 835 and 277CA, and connection to the Medicare eligibility system (HETS).

The first two services have been available for almost thirty years.  When they were introduced, access to these systems was achieved through a modem, phone line, and a remote terminal to the IBM mainframe computers running these services.  Now, decades later, this technology is still prevalent among providers who are still using the same methods to access this information and conduct these transactions.  Although many users have replaced the remote terminal with an emulator that can run under Windows on an existing PC, the technology connecting this emulator to the MAC systems still exists and is still supported by many MACs today.

modem blog

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Improving the Processing of NOEs and NOTRs for Hospices

As a vendor of eligibility processing services and a NSV (Network Service Vendor) for the Medicare HETS eligibility system, we have a vested interest in the capability of these systems to provide current and valid information. Through the HIPAA transaction for eligibility data (ANSI 270/271), we send requests to these systems for eligibility data for specific patients. Through a real time response, we can provide detailed information about the current status of this patient with the selected payer. This process involves converting the data returned by the payer into a report or entering it into a database.  In this process, we are the “messenger”. The content we provide is completely dependent on the quality of the payer response.

In some cases, these responses can be incomplete or inaccurate.  When this happens, we often get support incidents where providers complain that we are providing incorrect data. Most of the time, they are technically correct, but the issues they present as problems are beyond the ability of these payer systems to accommodate given the way this data is collected.

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Embracing Disruption for Growth

As we approach the October deadline for ICD10, you can sense the tension in the industry as the unknown consequences of using this code set move closer to the present as each day passes, or as Snoopy would begin the story, it was a dark and stormy night.

Even the most prepared organizations can only guess what the impact of switching to ICD10 will have on their transaction processing, cash flow, and procedures.  Every organization is linked to others and the disruption caused by this will be felt by everyone.  It can’t be avoided, only mitigated through planning, preparation, and then making adjustments quickly.

Charles M. Schulz, Snoopy
Charles M. Schulz, Snoopy

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The Impact of CMS Flexibility on ICD10 Implementation

CMS announced a joint statement with the AMA in early July regarding a compromise on how claims with 10 codes would be processed after 10/1/15.  They published FAQs and responses for this announcement on 7/27.

This announcement was advertised to be a settlement between these organizations regarding the efforts of the AMA to delay the implementation of ICD10 and the insistence of CMS that this deadline was final.

Initially, I was concerned about how this announcement might affect the adjudication of all Medicare claims and the potential modifications to Medicare contractor systems we had already tested with our applications over the last several months.  As it turns out, these changes to CMS policy are largely cosmetic and will have no impact on the processing of most claims.  Additionally, although this policy is promoted as a relaxation of the implementation, it provides little relief to healthcare providers and their staff that are unprepared for the transition.

Flexibility
Flexibility

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The Two Faces of CMS IT

As I mentioned in last week’s article, I attended the Healthcare Analytics symposium in Chicago a couple weeks ago.  During this meeting, Niall Brennan, CMS Chief Data Officer, spoke about recent advances and future enhancements to data and systems provided by CMS for the healthcare community.

He described the new “Blue Button Initiative” where CMS and the VA are providing the public access to “synthetic sample data sets for the purpose of fostering innovation and enabling industry stakeholders to provide feedback for future development.”

He discussed the new CMS Virtual Research Data Center (VRDC).  This system allows users to access approved data files within a virtual environment that is supposed to keep this data private and secure.  Users can purchase their own workspace in this environment and upload their own data to generate queries against related CMS information.

Two Faces of CMS IT

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Opposition to ICD10 – A Perspective of Self Interest

Last week I read several articles about the current efforts to delay the implementation of ICD10 by the AMA and some of our congressmen, possibly influenced by this organization.  Their extremely weak arguments against implementation focus on their own lack of preparedness for the implementation.  Anyone with any knowledge of what has already been done to prepare for this new code set would realize that the negative impact of another delay would far outweigh any benefits of allowing these procrastinators additional time to prepare.

ICD10 Coding
Opposition to ICD10

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ICD10 and Medi-Cal Processing – Preparing for Chaos

As the ICD10 deadline approaches, providers and health plans (and their vendors) prepare for the transition with varying levels of effort, efficiency and success.  Although it is true that the organizations that plan, train and test for this event will be more prepared for the transition from ICD9 to ICD10 than their competitors, no organization will avoid the consequences of an industry that seems to struggle with change.

What will happen when Medicare requires the ICD10 codes and other health plans are unable to accept them?  From the provider perspective, the bottom line is receiving reimbursement for your services.  Regardless of the “rules”, providers have always had to comply with reality to get their money.

prepare for chaos
ICD10 Chaos on the horizon.

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CMS End-To-End ICD10 Testing – April Results

CMS conducted the second round of end-to-end testing of claims with ICD10 data during the third week of April. MEDTranDirect, and one of our customers, Kimble Hospital of Junction, TX, were selected by Novitas for this round of testing.

As part of the testing process, 30 claims were sent for processing through our 837Direct product in a single batch. Most contained ICD10 codes and future dates, some contained ICD9 and current dates. All the submitted claims processed properly and the corresponding 999s and 277CA records were received.

In addition, CMS provided test 835 electronic remittance files that contained payment and adjustment data for the test claims reflecting how they will be paid in October.

ICD10 Testing
ICD10 Testing

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