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CMS’ Holds Second Open Door Forum on its Upcoming Pre-Claim Review Demonstration

On June 28, 2016, CMS held its second special open-door forum (ODF) regarding the Pre-Claim Review Demonstration for home health services (the “Demonstration”). The Demonstration will take place in six states (Illinois, Florida, Texas, Michigan and Massachusetts), all initiating by January 1, 2017, with the earliest start being August 1, 2016 in Illinois. However, as the initial implementation date approaches, home health agencies (HHAs) continue to express concerns regarding the Demonstration. CMS maintains that this Demonstration will benefit HHAs in the long run, but no matter whether or not they agree, HHAs across the country, particularly those located within the six Demonstration states, are paying close attention to the new developments.

The interest in the Demonstration was made evident by CMS’ statement that there had been 2,600 participants in the first open door forum on the Demonstration, which took place on June 14, 2016. CMS also gave repeated notice regarding its Demonstration FAQ page, which had been updated as recently as four days prior to the second ODF, and may be updated again before the Demonstration begins. Following these preliminary remarks during the second ODF, as well as a rehashing of the Demonstration’s basic tenets, CMS went right to the question and answer period.  The moderators were uncertain about some issues, such as to whether an electronic referral order would fulfill the plan of care requirement—but on other questions CMS was very sure and adamant in their answers.

The main focus of the ODF, due to the continued interest of HHAs, was the plan of care requirement.  During the second ODF, CMS clarified that in order for a pre-claim review request (PCRR) to be approved, HHAs must submit a physician signed and dated plan of care. Several callers commented that this would impose an undue hardship onto HHAs because of the difficulty already associated with physicians signing plans of care. The HHAs explained that requiring signed plans of care prior to submitting their PCRR would be substantially burdensome and had the potential to lead to delayed or unfiled PCRRs.  The HHAs also opined that despite CMS’ insistence that the Demonstration would not alter documentation requirements, demanding signed plans of care so early in the certification period appears to heighten the requirements as set out in the current regulations.  Relevantly, Chapter 7, Section 30.2.4 of the Medicare Benefit Policy Manual states the following: “The plan of care must be signed and dated by a physician […] before the claim […] is submitted for the final percentage payment.” Despite this, CMS held firm to its stance that the Demonstration did nothing to limit coverage and imposed no new requirements, citing that beneficiaries had always needed to be under a physician’s care. And while technically true, there is undoubtedly a new encumbrance upon HHAs’ Medicare reimbursement, as the Demonstration would require that the plan of care is submitted not only prior to the final claim, but also prior to the PCRR.

Another question which arose multiple times was in regards to new Medicare Administrative Contractor (MAC) employees. CMS stated during the first ODF that MACs would hire new reviewers in order to handle the PCRRs under the Demonstration, and many participants in the second ODF were concerned with the credentials—or lack thereof—of the new MAC employees. However, CMS assured the HHAs that all MAC reviewers would be nurses, as is the current standard, and that these nurses would be trained properly and sufficiently so that PCRRs would not be denied arbitrarily. As for the specific training that the reviewers would receive, CMS said that it would vary depending on the HHA’s regional MAC, and that HHAs should direct all questions regarding training regimes to their respective MACs.

CMS also established other points, such as the fact that reviews of pre-claims would be all-encompassing and would cover all potential deficiencies in the documentation, as opposed to issuing a PCRR denial for Reason X, and then denying for Reason Y upon resubmission of the PCRR. Another topic was Requests for Anticipated Payment (RAPs). An HHA asked if an extension would be added to the RAP payment period, which currently ends automatically after 90 days. This apprehension came due to the resubmission of PCRRs; while under the Demonstration PCRRs can be resubmitted an unlimited number of times in order to meet the requirements for approval, RAP payments will continue to automatically cancel within a required time period set by CMS. CMS made it clear that the RAP time period would not be extended, but mentioned that the initial PCRRs had a processing timeframe of 10 days, while resubmissions thereof had a period of 20 days. This theoretically allows for multiple resubmissions before the RAP payment period terminates, but also disillusions HHAs on the idea of ‘unlimited’ resubmissions.

Upon continued challenges on the issue of RAPs and other topics, CMS stated that it would take all questions and concerns under consideration, and that HHAs should monitor CMS’ Demonstration FAQ for any potential updates.

During the second ODF, CMS reiterated that PCRR non-affirmations would not be appealable, but that HHAs would need to submit the PCRR denial’s unique tracking number (UTN) along with their final claim in order to receive an appealable claim denial. The denial’s UTN would automatically cause the final claim to be rejected, at which point the HHA would be able to appeal as usual. In order to adequately mount such an appeal, or to avoid PCRR denials in the first place through compliance with Medicare requirements, HHAs should implement proactive compliance measures to verify appropriate documentation practices.

For over 30 years, Wachler & Associates has represented healthcare providers and suppliers nationwide in a variety of health law matters, including compliance with Medicare regulations and appeals of claim denials. If you or your home health agency have any questions regarding compliance with the new pre-claim review demonstration or other healthcare laws pertaining to Medicare or Medicaid, or healthcare regulatory compliance in general, please contact an experienced healthcare attorney at (248) 544-0888, or via email at You may also subscribe to our health law blog by adding your email at the top right of this page.