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Pre-Claim Review for Home Health: 5 Lessons from Illinois

by Sharon S. Harder

Pre-Claim Review has been underway in Illinois since August 2016, and it will soon take effect in Florida starting April 1, 2017. It's also still planned to roll-out in three other states (Texas, Massachusetts, and Michigan) on a yet-to-be-determined schedule.

Agencies in Illinois have learned valuable lessons from the Pre-Claim Review project. Agencies in other states will be wise to take heed and learn from Illinois. Here are 5 lessons relevant to all home health agencies:

  1. Save time by ensuring that your agency acquires the Face-to-Face Clinical Encounter documentation at the time of admission rather than waiting until later to request it. With this information in hand at the SOC, the assessing clinician will be able to know if there are gaps in the documentation that will need to be filled by the agency’s information.
  2. In establishing the reasons each patient is homebound during the assessment, use language that aligns with CMS’ rules. For example, “it is difficult and taxing for the patient to leave home because [state the reason].” If there is a medical contraindication for leaving home, such as the patient being prone to infection, associate that medical contraindication with a patient diagnosis in the assessment narrative.
  3. Assessments and homebound status narratives should be clearly focused on the patient’s structural and functional impairments and activity limitations.
  4. For recertifications, the physician estimate of how much longer care will be required should be specifically stated in terms of days, months, or even years. Statements such as “lifetime” or “whenever the patient has better living arrangements” are not responsive to the expectation.
  5. For each episode that will be reviewed, establish a checklist that agency staff can use to get the submission information together. This will speed up the document acquisition and submission process. Use the checklist to describe the type of facility that the patient was in prior to his/her home health admission. If an inpatient physician or NPP performed the Face-to Face Encounter, use the checklist to identify whether that individual is an NP, clinical nurse specialist, certified nurse midwife, or physician assistant.

Want to learn 5 more Pre-Claim Review lessons from Illinois?
Download our free white paper here: Face Up to Pre-Claim Review: What Your Agency Needs to Do Now

Read more in: Administration, Billing, Clinical, Coding, Legislation

About Kinnser software

Kinnser Software, Inc. provides web-based solutions that deliver clinical and business results to the home health, hospice and private duty industries. Founded in 2003 and headquartered in Austin, Texas, Kinnser Software serves more than 4,000 home health, therapy, hospice, and private duty home care providers nationwide. Kinnser helps thousands of clinicians and other staff in post-acute healthcare to manage scheduling, billing, electronic visit verification, day-to-day operations, and patient referrals. 

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