Home Health & Hospice Week

Physician education by CMS is a must.

Home health agencies in Pre-Claim Review’s first — and currently only — state are fighting to get the demonstration suspended there as it has been in the other four states slated for the demo project.

However, in this election year, it’s highly unlikely that Congress will pass legislation requiring the PCR pause. And the Centers for Medicare & Medicaid Services is not receptive to the idea either, industry reps report.

In lieu of complete elimination or suspension, agencies under PCR would like to see these changes to avoid the death knell under the program:

1. Scale back. CMS should reduce the number of claims reviewed under PCR, urges Sara Ratcliffe, Executive Director with the Illinois Home Care and Hospice Council.

CMS contends that the documentation it is requesting should already be completed by the physician and agency, so PCR should be little to no extra work. “That’s not true,” says Chicago-based regulatory consultant Rebecca Friedman Zuber. The PCR request submission process is very cumbersome, and compiling and submitting the requested documentation takes a significant amount of extra work.

CMS can relieve some of this burden by reviewing a portion of claims rather than 100 percent, Ratcliffe tells Eli. Choosing random claims for PCR review would keep agencies on their toes, but limit the submission workload.

2. Streamline. The current eServices portal for submitting Palmetto GBA PCR requests requires multiple submissions of documents, among other unnecessary burdens, Friedman Zuber reports. CMS and its MACs can significantly lighten agencies’ loads with some technical simplification.

3. Improve consistency. Right now, HHAs report review results that are all over the board. “I do continue to be disappointed by Palmetto’s inability to be consistent with its review process,” says reimbursement expert M. Aaron Little with BKD in Springfield, Mo. “We continue to hear about documentation being non-affirmed that seems the same as documentation that was affirmed. Very frustrating when cash is completely dependent on the process.”

The MACs need medical review leadership to educate their frontline reviewers, many of whom seem new to the process of home health claim review, Friedman Zuber says. “It won’t be easy, but they can improve from where they are now.”

4. Provide specific feedback. HHAs have complained of vague non-affirmation reasons since the program began, and it still continues.

Tool: CMS did update and expand its list of PCR reason codes and statements in a document issued Oct. 14 at www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Pre-Claim-Review-Initiatives/Downloads/Home-Health-Services_PCR_ReasonCodesAndStatements-101416_FINAL.pdf. But that list still leaves questions, with some codes and statements seeming “off base or inaccurate,” Friedman Zuber tells Eli.

5. Educate physicians. “One of the primary issues since the home health face-to-face encounter requirement was implemented has been a lack of education of physicians by CMS regarding the type of documentation required to qualify a particular episode of home health care for reimbursement,”

IHCC said in an Oct. 4 letter about PCR to CMS Acting Administrator Andy Slavitt. “Sadly, in addition to changing the requirements repeatedly in the years since the requirement was implemented, CMS

has pretty much left it up to home health agencies to educate physicians about what CMS and its contractors expect. This has led to ongoing unease between home health agencies and physicians, with conflict and frustration on both sides.”

“Physician education should have been a significant focus for CMS all along, but particularly prior to implementation of the pre-claim review demonstration program,” IHCC told CMS. “The program is designed in such a way that agencies must assume significant financial risk prior to learning whether the documentation provided by a party outside the agency’s control meets the CMS and MAC requirements.”

6. Release more PCR data. For this program to work, CMS needs to be forthcoming with relevant information. “IHHC would like for CMS to collect data on the number of Medicare beneficiaries who discontinue their home health care as a result of receiving a letter from the MAC telling them that their care is not covered by Medicare,” the association said in the letter. It also wants to see details on each type of decision (full affirmation, partial affirmations, and non-affirmations); resubmissions; more specifics on non-affirmation reasons; and claims/reimbursement volume compared to pre-PCR volume, among other items.