On August 3, 2016, the Center for Medicare and Medicaid Services (CMS) initiated the Pre-Claim demonstration to minimize cases of fraud and inappropriate billing by requiring that agencies prove claims authenticity earlier in the care period. The rollout was first introduced in Illinois, with scheduled demonstrations in other states that have since been postponed.
CMS sees pre-claim as an eventuality rather than a possibility, and experts anticipate significant rates of denials, delayed payments and complicated appeals as part of the big transition.
If pre-claim is pending for rollout in your state, there are measures agencies can take to increase rates of accepted documents and minimize risk of denied or delayed payments:
1) Train clinicians to improve their notes by reviewing your agency’s documentation protocols.
2) Manage the overwhelming paperwork with innovative approaches like IT solutions and process outsourcing to take the burden off and save staffing costs.
3) Organize a system for collection and submission of the required documentation for the pre-claim review request. Efficient tracking mechanisms should be put in place to monitor which episodes are submitted and their status in the pre-claim process. It should also track reviewer’s decision for each request.
“Prior to submission, agencies must pay attention to presentation of documents– it should easily be understood by the reviewer. A summary page of cases will be helpful. The goal is to prove in the simplest manner, that a specific care is medically necessary to each patient’s claim.”
4) Reposition your workforce and evaluate internal processes to integrate pre-claim review request monitoring.
5) Educate patients about the current situation and make them aware of concerns and changes that might occur. Assure them that care and services will maintain as it is, if not improved.
Outsource QA with Qavalo
Leave the QA work to our trained RN’s and stay on top of the pre-claim work. You can save up to 40% in salary and overhead costs with our competitive and flexible outsourcing services.
We’re more than happy to offer you a FREE TRIAL anytime and experience how Qavalo can help bring your company to the next level.
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