Home Health & Hospice Week

Nearly half of nation’s HHAs will be under PCR by January.

The heavy burden of Medicare’s new preclaim review demonstration is going to slam into home health agencies in the first demo state Aug. 1, while they are still scrambling to ready themselves for the onerous new requirement.

HHH Medicare Administrative Contractor Palmetto GBA has announced that it will be ready to accept PCR requests from Illinois HHAs July 15.

But because the demo applies to episodes beginning Aug. 1 and later, and the request can’t be submitted until after the Request for Anticipated Payment (RAP) — which itself can be submitted only after the first billable visit — HHAs actually won’t submit pre-claim requests earlier than Aug. 1, notes Chicago-based regulatory consultant Rebecca Friedman Zuber.

The Centers for Medicare & Medicaid Services is still sticking to its timeline to roll out the PCR demo in Florida Oct. 1, in Texas Dec. 1, and in Michigan and Massachusetts Jan. 1, according to the presentation for a PCR implementation workshop series conducted by Palmetto in Illinois. The MAC is conducting in-person PCR educational workshops throughout the state sponsored by the Illinois Homecare & Hospice Council, Friedman Zuber notes.

When PCR requirements are in effect in all five demo states Jan. 1, about 44 percent of the nation’s agencies will be under the program, according to data on data.medicare.gov. The data updated July 13 indicates that there are 758 Medicare HHAs in Illinois, 1,135 in Florida, 2,617 in Texas, 637 in Michigan and 225 in Massachusetts — all of which will be under PCR requirements when the demo takes effect.

Don’t be surprised to see the rest of the states subjected to PCR soon thereafter, experts say.

Palmetto notes in its workshop that the payment error rate found for HHAs is expected to jump to 59 percent for 2015 under the Comprehensive Error Rate Testing program. CMS is keen to get that figure down, and hopes PCR is the way to do it.

Follow This Roadmap For Documentation

When CMS first issued its operational guide for the demo, HHAs were disappointed at the lack of specifics as far as what to submit to substantiate the claim (see Eli’s HCW, Vol. XXV, No. 25-26). CMS instructed HHAs to look out for more specifics from their MACs.

Now Palmetto and CGS have issued a more detailed “task list” to help agencies know what to submit documentation-wise (see box, this page).

But that task list is still frustratingly vague, contends attorney Adam Bird with Liles Parker in Washington, D.C. The new list “does provide a tentative roadmap for agencies trying to figure out what documentation Palmetto’s reviewers will require to ‘affirm’ a pre-claim review submission,” Bird tells Eli. “But many agencies will likely still be in the dark when it comes to what specific documentation will be required to substantiate medical necessity and homebound status.”

For example: “Will the reviewers be satisfied with the start of care OASIS? Or will they want to see individual visit notes for services rendered up until the pre-claim review submission is made?” Bird asks. “CMS and Palmetto haven’t told us.”

Watch out: Face-to-face is going to be a major reason for “non-affirmed” decisions, experts predict (see story, p. 208).

And just obtaining the physician documentation on a tighter deadline will prove a serious challenge.

“Agencies are already under enormous pressure … to obtain physician orders within specified timeframes along with appropriate face-to-face documentation from the certifying physicians,” Bird says. “The pre-claim review project will only exacerbate those difficulties.”

In the meantime: Every single claim for HHAs in the demo states will undergo PCR review.

If an agency doesn’t submit a claim for PCR, it will automatically go to prepayment review, Palmetto explains in its workshop. “Agencies will now be expected to continue providing care to beneficiaries without any assurance that they will receive reimbursement for their services,” Bird says.

PCR Burden Looms With Electronic Medical Records

HHAs learned more about the mechanics of submitting their pre-claim requests, including that Palmetto wants agencies to use its eServices app for PCR submission.

Pros: With eServices, agencies can be sure their request was received and can receive decisions faster, Palmetto says in the workshop presentation.

And the eServices PCR submittal request form prepopulates some provider information to help reduce errors and save time, Palmetto says.

Cons: But the form lacks “a clear place to include a cover letter or other commentary directing the reviewer to the critical data elements in the documents,” Friedman Zuber criticizes. And “it is unclear at this moment whether more than one document can be uploaded for each component of the eServices template, which is their preferred approach,” Friedman Zuber tells Eli.

Using an electronic submission system could mean extra work for HHAs with electronic medical records, Friedman Zuber worries. “It will be truly ridiculous if an agency has to print an electronic document, scan it, turn it into a PDF and then submit it electronically,” she says. “What a waste of time and manpower,” she exclaims.

Timeliness, Quality Of Reviews In Question

Once HHAs make their PCR submissions, a whole new set of concerns about the review of those documents comes into play.

10 days? “Although CMS has stated that the MACs will ‘make every effort’ to review pre-claim submissions within 10 days of receipt, there is no assurance they will consistently meet this goal,” Bird stresses. “Unfortunately, the project guidelines announced by CMS do not contain any remedies for providers whose requests may be subject to lengthy processing delays.”

Agencies have seen some serious quality problems with reviews conducted under the Probe & Educate campaign focusing on F2F. Now they may see the same with PCR, Friedman Zuber fears.

The PCR guidance manual does not contain any requirements as to how detailed explanations of the non-affirmed claims will be. “If the MAC’s reasons for ‘non-affirming’ coverage are vague or nonspecific, as most unfavorable claim or appeal decisions by Medicare contractors tend to be, then many providers will be left wondering how to improve their documentation or what other records to furnish upon resubmission,” Bird predicts. “This could result in significant delays in reimbursement for many agencies and substantial negative impact on otherwise compliant providers.”

Note: See Palmetto’s PCR page, which includes links to the guidance manual, workshop slides, CMS FAQs, and more, by going to www.palmettogba.com — click on “Jurisdiction M Home Health and Hospice” in the blue “Medicare resources” box, then select “Home Health Pre-Claim Review” from the drop-down “Topics” tab, then click on the “Pre-Claim Review Articles” link. See CGS’s PCR website at http://cgsmedicare.com/hhh/medreview/pre_claim_review_demo.html.