Home Health & Hospice Week

Learn from original PCR run, trade group tells Medicare officials.

Unlike with the original Pre-Claim Review demonstration, home health agencies are hoping to head off the medical review project before it ever gets off the ground.

Timeline: Home health agencies have 60 days from the May 31 PCR Federal Register notice to submit comments on the revived demo.

Taking advantage of this opportunity is crucial, industry experts stress. “Agencies need to submit comments,” urges Healthcare Provider Solutions’ Melinda Gaboury on the HPS blog. “We not only need a volume of comments, but we need quality comments that express how unreasonable this situation is, especially when some of the demonstration states are already under Value-Based Purchasing and all of the demonstration states have Targeted Probe and Educate occurring on multiple agencies.”

Gaboury advises that “comments do not need to be lengthy, but they need to discuss the seriousness of this situation and how it will negatively impact your agency and patient care.”

“The home care industry is already subject to plenty of review fraud and abuse-wise, including MACs, ZPICs, RACs, OIG, etc.,” protests Washington, D.C.-based healthcare attorney Elizabeth Hogue. “If this isn’t enough to solve any real problems of fraud and abuse, as opposed to documentation that reviewers seem to think falls short, then it’s really stretching the rubber band to conclude that pre-claim review will solve the problems.”

Comments are due July 30. At press time, 27 comments had been submitted, according to www.regulations.gov. “We have to do better than this,” says consulting firm Kornetti & Krafft in its e-newsletter. “There are over 12,000 home health agencies in the U.S.”

Meanwhile, the National Association for Home Care & Hospice is planning to partner with Congress to oppose the program, which CMS is now calling the Review Choice Demonstration for Home Health Services. “We will be attempting to secure a congressional sign on letter that would go from Congress to CMS seeking a pause in RCD,” NAHC President William Dombi tells Eli.

Instead, NAHC and home care’s congressional supporters would offer more effective alternatives to achieve fraud prevention. Those alternatives could range from making RCD truly optional (with no penalty) to using claims sampling instead of reviewing every claim to using data analysis to target RCD review, Dombi suggests.

Which alternatives NAHC and home care allies in Congress will recommend will largely depend on the results of ongoing data analysis from PCR’s original run in Illinois, Dombi indicates. NAHC is examining data to discover if a potential home health spending reduction “is connected to certain HHAs or certain types of patients,” Dombi explains. “In addition, the data can help us understand whether the patients that lost access to home health ended up using more costly services such as inpatient hospitalizations and ER visits.”

Important: “There are valuable lessons to be learned from PCR in IL during 2016-17 that should be considered before triggering RCD,” Dombi insists. “We believe that taking advantage of what can be learned from eight months of PCR makes more sense that diving into RCD with its estimated cost of $400 million.”

Note: See the Federal Register notice and comment at www.regulations.gov/document?D=CMS-2018-0071-0001.