Home Health & Hospice Week

The demonstration has made some improvements, however.

The potentially unsustainable workload of the Pre-Claim Review program seems to be the biggest problem with the demonstration project poised for expansion. But PCR has a number of other operational issues as well that will make home health agencies’ lives difficult. For example: Getting ordering and certifying physicians on board continues to be a huge challenge. “We are at the mercy of the physicians,” laments attorney Robert Markette Jr. with Hall Render. Getting them to sign other providers’ records into their own record, as PCR practically demands, can be very difficult, he notes.

Plus: “There are occasional eServices kinks and weird interpretations from reviewers,” relates Chicago-based regulatory consultant Rebecca Friedman Zuber, who works with the Illinois Homecare & Hospice Council.

The Visiting Nurse Associations of America criticizes the education the Centers for Medicare & Medicaid Services and its contractors have promised as part of the program. “Much of the technical assistance has been one-on-one calls with quick instructions on specific language to use in documentation for individual claims,” VNAA’s Joy Cameron contends. “That is not training nor education. This is not indicative of a successful program and the demonstration should not proceed to the next state.”

And Palmetto GBA’s “template for submissions does not really encourage providers to submit all of the documents [the MAC’s reviewers] seem to want,” Friedman Zuber says. “Palmetto should be more specific about wanting these documents” — such as aide assignment sheets, visit notes, etc. — “in the Template because it would reduce confusion.”

Erroneous non-affirmations are still occurring, Cameron says. “These pre-claim reviews screen for far more than eligibility,” she criticizes. HHAs have “had scenarios where they are receiving nonaffirmations for not having interim orders for adding additional disciplines during the episode (those orders would come with the final submission of the claim) — something outside of the scope of PCRD.”

Some Positives

It’s not all bad news for Florida providers. At least they didn’t have to go first, like their beleaguered counterparts in Illinois.

“Illinois HHAs suffered through the MAC/CMS learning curve with PCR,” notes William Dombi with the National Association for Home Care & Hospice. “To an extent, that will be avoided by HHAs in Florida. Many of the MAC problems involved errors in processing documentation — including losing it.”

Also: “The MACs erred in the determinations issued, but those have declined in Illinois,” Dombi adds. “Since PGBA is also the Florida MAC, we hope that the improvements will continue.”

A silver lining to PCR’s implementation has been that “Palmetto has been very good at working with us during the past couple of months to address specific instances of errors on the part of reviewers and generalize them in their training,” Friedman Zuber says. “And they are listening to us when we bring up more systemic issues — our working relationship is very constructive.”

More good news: “The process is certainly smoother than when it began,” Friedman Zuber says. “The turn-around time on submissions is currently almost uniformly very quick and if a reviewer concern can be dealt with during a phone call (e.g., no additional documents need to be submitted), then a potential non-affirmation or partial non-affirmation can be averted.”