Home Health & Hospice Week

Pre-Claim Review will ‘change home health as we know it,’ expert warns.

Illinois home health agencies continue to suffer under the burdensome Pre-Claim Review program, and no end is in sight. The delay that is giving much needed relief to HHAs in Florida, Texas, Massachusetts and Michigan doesn’t affect the state in which PCR is already operating.

“It is absolutely frustrating that Illinois patients and home health care providers … will not be granted the same reprieve from this devastating and disastrous program as those in other states,” says Sheila Guither, president of the Illinois HomeCare and Hospice Council. If PCR is not halted in Illinois, “it will result in fewer providers, leaving patients without necessary services,” warns Guither, a manager with OSF Home Care Services in Normal.

The non-affirmation rate is running from 60 to 80 percent in Illinois so far, according to industry and government reports (see story, p. 270). One Illinois HHA tells the National Association for Home Care & Hospice it has yet to receive a single affirmation under PCR.

NAHC reports one HHA’s closure in Illinois due to the program already, with other agencies on the verge of shut-down. “These closures will cause patients to go without the care they need and provider jobs will be lost,” NAHC says in its member newsletter.

Agency closures “will ultimately result in patients seeking out more costly institutional and acute care, which will cost [the Centers for Medicare & Medicaid Services] more money and have a negative effect on our patients’ quality of life,” Guither tells Eli.

CMS and HHH Medicare Administrator Palmetto GBA acknowledge that there have been some problems with the PCR process thus far. Palmetto has fixed some problems, such as not being able to “save” a submission in progress, and has more “enhancements” to the portal in the works, a Palmetto rep says.

“CMS and the MAC are actively working to resolve … submission issues as quickly as possible and are continuously working to find ways to improve the web portal experience for providers,” a CMS spokesperson tells Eli. “HHA providers continue to have the option of submitting their requests via fax or regular mail if they are unable to use the MAC web portal,” CMS adds.

Of course, a faxed or mailed submission means a faxed or mailed reply, which causes a time delay in the PCR turnaround process.

Tip of the iceberg: The PCR problems are only beginning in Illinois, Guither contends. “Auditing of Pre-Claim Review submissions has been inconsistent and nonsensical, making submission of the necessary paperwork a guessing game,” Guither blasts. “This has not improved, nor has the complexity of the submission process. We have not yet met full submission capacity in Illinois and the non-affirmation (denial) rate is anywhere from 60 to 80 percent across Illinois. As more and more patients are added, the problem will be compounded.”

Many Illinois agencies have had to hire additional staff to accommodate the PCR burden, Guither recounts. “Others are unable to do so, requiring them to divert staff from other duties, including nurses, who should be spending time on patient care, not gathering paperwork,” she says.

Resource drain: “Submission can take up to an hour to complete,” Guither explains. “Depending on the size of the organization, and the number of patients admitted each week, this can take thousands of hours a month.”

And getting physicians to cooperate remains a huge challenge. The current F2F requirement has “made this demonstration project unmanageable for providers,” judges Bobby Lolley with the Home Care Association of Florida. “Physicians simply have no impetus to work with agencies, and that has to be addressed by CMS.”

Bottom line: If Pre-Claim Review continues as it is, Illinois agencies will be forced to close their doors, Guither says. “Pre-Claim Review is a devastating disaster that [CMS] needs to stop so that patients can receive the care they need, in the place they want to be: Home.”

And PCR’s implications reach beyond Illinois. “If implemented on a large scale, it will change home health as we know it,” Lolley warns.