The State of Pre-Claim Review: A Report From Illinois

Homecare Homebase Chief Strategy Officer Scott Pattillo participated in a recent webinar sponsored by Home Health Care News. Pattillo and other industry professionals described the effect of the CMS Pre-Claim Review pilot project (PCR) and industry efforts to implement changes in the new program, which began in Illinois last August and has come under intense scrutiny after mixed results.

PCR Creates Paperwork Backlog and Staffing Issues

The webinar panelists found that many Home health agencies (HHA) have struggled with the extra time and staffing required to submit PCR forms, educate physicians and reassure clients. The added paperwork and information gathering is straining providers' ability to comply, so many are adding extra staff to prepare and submit documentation. This isn't just routine paperwork that clerical staff can handle; many agencies have to place nurses in those jobs instead of lower-skilled employees.

Deborah Bradley, Home Health Manager of Clinical Operations at Riverside Healthcare, described the problems during the session:

"It's time consuming for everyone. It takes about an hour for each patient. It takes an extra 20 minutes to half an hour for my medical records staff - on each patient. Imagine 300 patients and it's a lot of time. Our docs are frustrated and so are our referral resources.  We've had a decrease in our referrals this past month. I can't directly relate it to PCR, but I do feel like it's impacting that."

Resubmissions Causing Cash Flow Problems for Some Agencies

 The Medicare Administrative Contractor (MAC) has 10 days to review the PCR documentation. If the claim isn't affirmed, the agency can resubmit as many times as necessary, but MAC at that point has 20 days to review resubmissions. Each non-affirmed claim has to be reviewed by an employee who then has to resubmit. This means extra time, effort - and cash flow problems that result from delayed payments.

Others Reporting “Panicked Calls” from Patients

 Another issue with non-affirmations is that the same denial paperwork is sent to both the HHA and the client. Few home health clients have the medical background necessary to understand the verbiage. All they know is that Medicare has denied their claim. Agencies report "panicked calls" from clients; some have even canceled their service because they don't have the funds to pay for care themselves if Medicare denies the claims. The uncertainty causes a lot of stress for patients, families, and caregivers.

Agencies Working with CMS to Reduce Non-Affirmations 

During the first month of implementation, Illinois HHAs saw non-affirmation rates between 60% and 80%. That has dropped to an estimated 40-50% of claims. Agencies have worked together with CMS to reduce these numbers.

Initially, agencies received non-affirmations with no feedback, just flat denials. CMS recently updated the FAQ page to add reason codes that help pinpoint documentation problems. Providers say they need more custom feedback - not just stock language and denial codes.

Agencies say that the initiation of person-to-person contact between providers and MAC reviewers is the most beneficial change to date, and has helped reduce non-affirmations. MAC reviewers now call HHAs to explain problems before sending determination letters. For instance, if a reviewer can't find a document, the agency can point the reviewer to the information. This interaction means that a reviewer can reverse a decision before sending the letter, eliminating the need to resubmit.

More Training and Communication Needed

Florida had been scheduled to begin a pilot PCR project this fall, but the problems in Illinois (and Congressional pressure) have delayed it at least to the beginning of 2017. One reason given for the postponement was "lack of adequate training," but participants noted that CMS hasn't announced any plans for additional training in either Florida or Illinois. CMS did send a letter to Illinois physicians about the program in mid-September - six weeks after implementation had begun.

This lack of physician training forced HHAs to step up and help educate doctors and hospitals about the documentation requirements. This piecemeal approach has frustrated physicians, in particular.  Some have stopped making home health care referrals until the issues can be sorted out. A few agencies report that their referrals have fallen since August, but note that it's too soon to blame PCR for the drop. 

While physicians complain about the additional paperwork requirements, clients fret about delays in receiving care. Some HHAs are delaying referrals until they get the face-to-face (F2F) documentation they need for PCR. So far, PCR appears to be a drag on care delivery and payment in Illinois.

Making PCR Documentation Flow More Smoothly

Currently, most information regarding lost referrals, increased time/staff for paperwork, and cash flow issues is anecdotal. The program is so new that agencies don't have all needed evaluation tools in place yet. Home health software companies are working to provide clients with tools to streamline the PCR submission process.

Pattillo described the efforts of Homecare Homebase's:

"In this process, more than most, tech plays a vital role in compliance and helping agencies manage the operational burden. If your tech is helping you complete the documentation, it puts you in a strong position to begin with to complete your PCR documentation. We've focused on automating submissions, which can help you recognize trends in affirmation and non-affirmation and gain insights into improving your process.  It's a regulation that's particularly ripe for technology."

The other panelists agreed that software tools which structure PCR workflows will help their staff locate, organize, and submit packets - hopefully resulting in higher affirmation rates and fewer delays. The most successful agencies have already begun to streamlining procedures with filing, databases and organization changes that help them respond more quickly and accurately.

What's the Future of PCR?

Panelists agreed that there is fraud in the system and noted that there are a number of existing indicators that help investigators find and stop fraudulent providers. However, they also assert that PCR is a huge burden on agencies, and there is no data yet to show that it reduces fraud. There may be a better way, providers say, so they're asking CMS and Congress to re-evaluate the program.

Many agencies, panelists said, are holding some cases back and not submitting PCR paperwork. They're waiting to see what works, hoping someone will find the "magic formula." Others are just hoping the whole process gets scrapped, but it's dangerous to count on that. HHAs in states targeted for the pilot project get 30 days notice before it begins. That's not a lot of time to put a plan in place if you're in one of those states.

Agencies in pilot states should already be preparing for PCR. Study and streamline your internal procedures. Provide outreach to physicians and other providers to educate them about the new requirements. And pay close attention to developments in Washington as the new Congress convenes. Industry trade organizations will be pushing for change, but nothing is certain at this point.