Getting Ready for Pre-Claim Review (again): Steps to Success

The Centers for Medicare and Medicaid Services (CMS) announced on May 31 that it was revisiting the 2017 Home Health Pre-claim Review Demonstration in an expanded way. The move comes after a more than year-long halt of its previous Pre-Claim Review Demonstration for Home Health Services in Illinois. According to the CMS, the new Review Choice Demonstration will help uncover and reduce the amount of fraud in the system, but gives providers more flexibility and choice in the way compliance reviews are handled.

Under the new proposal, home healthcare providers will be able to choose between three options – pre-claim review, post-payment review, or minimal post-payment review with a 25% payment reduction for all home health services. The proposed five-year demonstration will be implemented with the Medicare Administrative Contractor (MAC) for Jurisdiction M, Palmetto, in five states: Florida, Illinois, North Carolina, Ohio, and Texas. While comments collected through July 30 here may shift the review rules, agencies should be preparing their processes for this change. Experts believe it is only a matter of time before the demonstration is rolled out on a wider basis.

CMS expert Diane Link, director of clinical services for BlackTree Healthcare Consulting says agencies need to get ready. “This is going to require agencies to have good processes in place in order to submit every single claim effectively,” she says. “It’s definitely going to impact cash flow.”

Making the Right Moves

There are several things a home health organization can do to get ready for Review Choice Demonstration. Link says leaders should start by taking inventory of responsibilities – for example: which employees are doing submissions and which are reviewing those submissions. In some cases, a simple personnel check like this may show you that you need to hire more employees, she says. “The biggest issue is always going to be making sure a face-to-face encounter meets requirements and getting those signatures as quickly as you can,” she says.

This is where an order management and tracking system can really help. While some EHRs do have these types of functionality, many are not effective enough on their own, says Link. “You need to be able to track when the documents go out to Palmetto for review.” That’s why order management is so important, she says. Agencies don’t want to have to wait two weeks to follow up with a doctor for the first time. 

Deborah Buenaflor, Director of Product Management at Forcura has been evaluating our pre-claim review solution for the past two years and says this need -- to track documents -- is one of the things that prompted us as a company to add the ability to group documents. Forcura users can sort documents in the Forcura document workflow platform by type and status so users have transparency of a document’s status according to a specific workflow such as Review Choice Demonstration. “It gives our users the knowledge of who they need to reach out to in order to get a document processed so their organizations can get paid in a timely manner,” she explains. “We also make it possible to add notes or annotate on a document so Palmetto can easily correlate documents submitted to the appropriate task.” 

Kim Gaffey is CEO and Founder of Gaffey Home Nursing & Hospice and one of Forcura’s first customers. She participated in the Illinois pre-claim review pilot in 2016. Gaffey worked with the product management team to help streamline the documentation process. Over and above just the process though, Gaffey learned that education is paramount to success.  “There was a lack of education for physicians,” she explained to us. “We really had to educate the local hospital and the local physicians so they understood what we had to do. Now, with the new review, we’re currently coming up with a pocket-sized tip card to leave behind that has simple instructions about face-to-face, what homebound status is, and what the physician has to dictate in his or her notes in order to be compliant with a home healthcare referral.”

Experts also say home health teams need to be on top of patient history. Link, for example, says agencies in Illinois that participated in the first pre-claim review trial got into trouble when they failed to submit prior certifications. “If I'm [working on documentation for a] client that's been on service for more than one episode, remembering to submit that first episode information also,” is important, she says. “Most of the times what the MAC wants is the initial episode certification  and the subsequent episode certification, so if they've been on for 10 cert periods they [MAC] wants number one, number nine and 10.”

Reviewing Other Options

Since the revised pre-claim review can be daunting, there may be some home health companies considering post-claim reviews or – if they are working with huge margins – may opt to forgo the review process completely, taking a 25 percent reduction in fees. One expert says these options are not sustainable or smart.

“I really don’t know how an agency would do a post-claim review,” says Link. “Why wait 60 days? You run the risk of having providers no longer available or providers who may not remember exactly what happened.”

Gaffey agrees. “I would much prefer to do a pre-claim review and know immediately if we need to gather more documentation. If you do a post-claim review, it’s hard to go back and gather more information. The information you need for pre-claim review – 80 percent of it – is coming from the referral source. And going back to that referral after 60 days is going to be very, very difficult.”

Success all comes back to technology, says Link. “Technology can streamline processes and make it easier for an agency to get paid in a timely fashion,” she says. Gaffey points to her own agency’s success with the Illinois pre-claim review process using technology.

Gaffey Home Nursing & Hospice’s first pre-claim reviews were in November 2016. At the inception, the agency was at 60 percent affirmations, with 40 percent of all its cases requiring more development. In addition, the entire pre-claim process took about 21 days. By the end of February 2017 with the right processes and technology to support them, pre-claim reviews took a mere six days and 100 percent of those claims were affirmed. These stats align with what we are seeing across the board with other clients that have previously rolled out pre-claim review processes. 

“Technology is absolutely the solution,” agrees Gaffey. “Without technology we’re talking about hand delivering and handwriting documents and having to send them back and forth, and there’s a huge learning curve.” 


Here at Forcura, we believe there are four simple things home health providers can do to prepare for pre-claim review:

  • Evaluate and understand your personnel and processes

  • Educate your constituents on the requirements

  • Be on top of your patient history

  • Invest in technology to streamline the process


We are committed to building technology that will help you do all of the above and so much more from a productivity standpoint. Our solutions have real world applicability and drive immediate productivity. In this industry, as is the case across all of healthcare, the only given is that regulations are a fact of life and that there will always be new ones. Our goal is to help our clients take a step back, evaluate the requirements and adhere to regulations in the most efficient and cost-effective way possible.

To learn more about our pre-claim review workflows connect with Deborah Buenaflor, Forcura Director of Product Management.

Annie Erstling leads strategy and marketing for Forcura. She has experience launching new brands, products and companies in the healthcare, technology, hospitality and consumer products industries on both the corporate and agency side of marketing. Connect with Annie on LinkedIn.

Topics: Care Coordination, CMS Regulatory Guidance

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