Home Health & Hospice Week

Know these 3 crucial differences between the old and new PCR program.

Just when you thought Pre-Claim Review was in your rearview mirror, Medicare has put the reviled prepayment review program back in the fast lane.

On May 29, the Centers for Medicare & Medicaid Services issued a Federal Register information collection proposal notice signaling its intent to resurrect PCR. "CMS proposes initially implementing the demonstration in Illinois, Ohio, North Carolina, Florida, and Texas with the option to expand to other states in the Palmetto/JM jurisdiction," says the notice published in the May 31 Federal Register.

This proposal took many industry experts, who thought PCR was essentially dead, by surprise.

Reminder: The original PCR demo began in Illinois Aug. 3, 2016, and was set to begin in Florida in April 2017 and then expand to the remaining three states of Texas, Massachusetts, and Michigan. But CMS "paused" PCR in Illinois and averted its implementation in Florida at the last minute on March 31, 2017 (see Eli's HCW, Vol. XXVI, No. 14).

The halt came after significant political pressure, including a letter to CMS from Florida lawmakers including U.S. Sen. Marco Rubio (R) and proposed federal legislation on the matter.

Now over a year later, CMS is back with a revised proposal.

Difference #1: CMS has swapped out two of the states proposed for inclusion in the demo. Instead of the original Illinois, Florida, Texas, Massachusetts, and Michigan, CMS wants to implement PCR in Illinois, Florida, Texas, Ohio, and North Carolina. That would trade the two states not served by HHH Medicare Administrative Contractor Palmetto GBA for two that are, National Association for Home Care & Hospice President William Dombi tells Eli.

Difference #2: In the previous version of PCR, HHAs had to submit claims for prepayment review or take a 25 percent penalty (after an initial grace period). In the currently proposed version, "providers in the demonstration states may participate in either 100 percent pre-claim review or 100 percent postpayment review," the notice says.

Difference #3: CMS specifies that agencies that perform well won't be on PCR forever. "Providers will continue to be subject to a review method until the HHA reaches the target affirmation or claim approval rate," CMS explains in the notice.

"Once a HHA reaches the target pre-claim review affirmation or post-payment review claim approval rate, it may choose to be relieved from claim reviews, except for a spot check of their claims to ensure continued compliance."

PCR Imposes Heavy Burden For Little Gain

While Medicare has made some tweaks to the program, they aren't enough to relieve the heavy burden PCR will impose. "Resurrecting PCR would undoubtedly be a significant administrative and cost burden for providers already operating on razor-thin and ever-reducing reimbursement rates," says the Home Care Association of Florida's Kyle Simon. "Much less burdensome approaches are available to CMS as the vast majority of 'improper payments' are due to minor documentation errors or omissions."

Reinstating PCR "is a significant imposition of administrative cost for the providers," says consultant Joe Osentoski with QIRT in Troy, Michigan.

"Any medium-size and up provider had to essentially dedicate at least one full-time employee to handle the prior version." Nothing about the program revisions will improve that, Osentoski expects.

PCR's burden will translate into access problems for patients, Dombi warns. "The program will be very costly to HHAs, as each claim would be subject to complex medical review that will involve significant paperwork and time for the HHAs," he says. PCR is likely to "trigger a 'chilling effect,' dissuading HHAs from serving Medicare patients," he fears.

HHAs in Illinois are hopeful that their PCR workload may be lifted due to the state's previous participation in the demo. "Many of our agencies achieved 100 percent affirmation rates the last time," says Sara Ratcliffe, executive director of the Illinois HomeCare & Hospice Council. "Will that be taken into consideration for this round? If so, the impact may be lessened but still it will be a disruption and another burden to comply with on the heels of implementing the new Home Health Conditions of Participation."

Another big change agencies must grapple with in the near future is Medicare payment reform, Simon adds.

Plus: "Florida home health providers are disproportionately subjected to too many complex and burdensome Medicare pilot programs and demonstrations, including the Home Health Value-Based Purchasing Model, which is in effect in nine states," Simon notes.

And all this burden doesn't really achieve much, Simon maintains. The original PCR demo in Illinois "did not result in any substantive fraud or abuse findings; rather it turned into an audit of documentation," he says.

Note: The Federal Register notice is at www.gpo.gov/fdsys/pkg/FR-2018-05-31/pdf/2018-11492.pdf.