Home Health & Hospice Week

For the first time, CMS reveals partial affirmation rate.

Home health agencies in Pre-Claim Review’s first state are struggling under the program, even as affirmation rates rise.

Through Nov. 5, the demonstration program’s 13th week, the affirmation rate rose to 82 percent, the Centers for Medicare & Medicaid Services reports on its PCR website. That compares to 66 percent in week 8 and 78 percent in week 11, CMS points out.

Remember: That affirmation rate includes “provisionally affirmed or partially affirmed decision[ s],” CMS clarifies. So even claims that are drastically reduced in reimbursement count in the affirmed rate.

However, the partial affirmation rate was relatively small in week 13 — only 5 percent of affirmed claims were partial. The remaining 77 percent were full affirmations.

That’s the first time CMS has broken out the partial affirmation rate, notes Sara Ratcliffe with Illinois Home Care & Hospice Council.

And the program is far from full volume, with only about a quarter of Requests for Anticipated Payment having accompanying PCR requests so far, according to CMS’s week 11 data.

Plus: “Only about 230 agencies out of the more than 750 Illinois HHAs had submitted PCR as of 10/21/16,” the last date for which CMS has released such data, Ratcliffe tells Eli.

Prediction: Don’t be surprised to see affirmation rates fall again once the program is running at full capacity. “I suspect, once all agencies are submitting PCR the affirmation rate will go down,” Ratcliffe says.

PCR Review Overreaches

“Ultimate affirmation rates are rising,” allows Chicago-based regulatory consultant Rebec-ca Friedman Zuber. However, “it often takes multiple tries,” Friedman Zuber says.

In week 11, CMS reported “wide variation in the affirm rates of HHAs. Some HHAs have a 100 percent affirm rate and some have a 0 percent affirm rate. Many HHAs lie somewhere in the middle.”

The wide variation may be because some agencies are “starting to figure out what they want,” Friedman Zuber says. What reviewers are looking for “is way beyond just determining whether the face-to-face documentation provides a basis for the patient’s eligibility for home health services,” she continues. “It is much more a mini pre-payment ADR — and not so mini.”

Accordingly, “some of our providers have developed strategies for preparing their initial assessment and nursing notes that address the specifics that Palmetto wants,” Friedman Zuber says. In particular, that includes “documenting the patients’ functional, structural and activity limitations.

“This is above and beyond the CMS requirements,” Friedman Zuber adds.

Watch for: IHCC plans to offer education based on the strategies their members have gleaned from the PCR process so far, says Friedman Zuber, who works with the trade group.

Note: See CMS’s affirmation stats at www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Pre-Claim-Review-Initiatives/Overview.html.