Home Health & Hospice Week

Claims volume far from full.

Medicare is touting its improving approval rates in the Pre-Claim Review demonstration project, as the program seems poised to expand.

Stats: “As of Week 17, which ended on 11/26/2016, 87 percent of pre-claim review requests in Illinois received provisional affirmation,” the Centers for Medicare & Medicaid Services said in a Dec. 2 post on its PCR web page. That includes 83 percent that were fully affirmed and 4 percent that were partially affirmed, CMS specifies.

Good news: “The providers who are submitting are getting better at figuring out and providing what is wanted,” allows Chicago-based regulatory consultant Rebecca Friedman Zuber.

Bad news: But it may be taking agencies multiple submission to achieve those stats. “It is not clear how many agencies are receiving affirmations the first time around” from CMS’s data, points out Friedman Zuber, who works with the Illinois Home-Care & Hospice Council.

The stats also are not uniform, CMS said in its last update on Nov. 18. “CMS has seen a wide variation in the provisional affirmation rates among individual HHAs,” the agency noted. “Looking at decisions made through 10/29/16, CMS has seen that HHAs who have received more decisions generally have a higher affirmation rate,” the agency explained. “The average provisional affirmation rate of all HHAs combined who had at least 10 decisions was 81 percent. The average provisional affirmation rate of all HHAs combined with fewer than 10 decisions was 62 percent.”

The conclusion: “There is a strong correlation between the number of submissions sent by a HHA and the number of provisionally affirmed decisions received,” CMS said. “As experience with submitting pre-claim review requests increases and additional education, such as proactive outreach to HHAs receiving non-affirmed decisions, is conducted, more HHAs are increasing their affirmation rate.”

But Pre-Claim Review is far from full volume, Friedman Zuber fears. Now that the grace period is over and home health agency claims will get docked 25 percent of their reimbursement if they don’t go through PCR, expect to see that volume ramp up and affirmation rates fall significantly.

“Many agencies have sizable backlogs of PCR requests to file and final claims because of the demand involved in the program,” Friedman Zuber tells Eli. IHCC “would like updated info on RAPs and the percentage of agencies that are actually participating in the PCR program.”

Auto-cancel crisis looms: IHCC would also like CMS to release data on changes in the average time that elapses between RAP filing and filing final claims and how many agencies are in danger of losing their RAP privileges due to the auto-cancel threshold, Friedman Zuber adds. “That should be coming more clear now.”