Home Health & Hospice Week

P-A-U-S-E spells relief.

At long last, home health agencies are seeing the assistance they hoped for from the Trump administration.

On March 31, the Centers for Medicare & Medicaid Services announced a “pause” for the Pre-Claim Review demonstration program in Illinois, and a delay to Florida’s April 1 implementation date. “As of April 1, 2017, the Pre-Claim Re-view demonstration will be paused for at least 30 days in Illinois,” CMS said on its PCR website. “The demonstration will not expand to Florida on April 1, 2017.”

On the same day, CMS proposed a six month delay to implementation of the drastically revised and new Home Health Conditions of Participation (see story, p. 108).

In addition to the temporary halt, CMS told national and state trade groups in a meeting that it will be heavily revising the burdensome program, trade group reps tell Eli.

The delay is an “enormous relief” for Florida HHAs, says Bobby Lolley with the Home Care Association of Florida. “Over the past few years Florida providers have been the target of every single program or demonstration project that CMS could think of; the stress and strain of that reality cannot be adequately described.”

Illinois agencies have been living under that strain since the program’s launch in that state on Aug. 3, 2016. For many agencies in Illinois, the pause “is a huge relief and will definitely allow them to catch their breath,” says Sara Ratcliffe with the Illinois HomeCare & Hospice Council.

Halting the program temporarily makes sense, because it was “unnecessarily punishing the innocent along with the guilty,” says attorney Robert Markette Jr. with Hall Render in Indianapolis.

“It is clear that the PCR outcomes in Illinois were not meeting CMS’s objective of uncovering fraud,” notes Barry Cargill with the Michigan HomeCare & Hospice Association. Michigan is one of the five PCR demo states, although its rescheduled PCR implementation date hadn’t been announced after CMS made the first PCR delay back in September (see Eli’s HCW, Vol. XXV, No. 35).

Reminder: The original implementation dates for PCR were Oct. 1 for Florida, Dec. 1 for Texas, and Jan. 1 for Michigan and Massachusetts. The five PCR demo states contain about 44 percent of the nation’s agencies, according to data on data.medicare.gov.

Industry reps and providers were quick to offer thanks for the program’s delay and forthcoming revamp. “We are pleased that CMS Administrator Seema Verma has chosen to suspend the program while improvements are made, which we believe will protect patient care,” Kindred Healthcare Inc. CEO Benjamin A. Breier says in a release. “We thank Senators Rubio and Nelson and the members of the Florida congressional delegation for their leadership in advocating to replace the troubled PCRD program with a more effective integrity initiative that better targets fraud.”

“We appreciate CMS’s leadership to acknowledge the shortfall of the PCR program and to take a step back to re-evaluate the program,” Cargill says.

“The home health community has many to thank for this action, including the new CMS Administrator Seema Verma,” the National Association for Home Care & Hospice said in its member newsletter. “While many members of Congress stood out in support of home health care, virtually the entire congressional delegations from Illinois and Florida … deserve significant credit. [HHS] Secretary [Tom] Price and Congressman Jim McGovern who sponsored the legislation last year to suspend PCRD are also clear notables from the House of Representatives.”

Don’t Expect PCR Halt To Be Permanent

Many HHAs had hoped for an outright repeal of the punitive PCR program under the Trump administration. The HHA payment error rate, calculated under the Comprehensive Error Rate Testing program, “is clearly the driving force behind PCR,” Lolley says. The latest data for 2015 shows that error rate at 59 percent (see Eli’s HCW, Vol. XXV, No. 38). “That high error rate is based solely on the inadequacies and problems associated with the F2F requirement over the past years,” Lolley maintains.

Even better would be elimination or significant correction of Medicare’s home health face-to-face physician encounter mandate. “The best and most direct answer is to fix the F2F requirement,” Lolley says. “But unfortunately Florida providers, and providers across the country, will be forced to accept the responsibility for that ‘error rate.’”

While F2F revision and PCR elimination haven’t taken place, the temporary halt isn’t a bad substitute.

“A pause is a good step toward being able to evaluate the Illinois PCR experience and develop measures that are not burdensome to agencies, yet work to improve program integrity,” Ratcliffe says.

“The home health industry in Michigan would like to see … CMS leadership and the home health industry from across the nation work together in true partnership to improve services for Medicare patients,” Cargill says.

CMS hasn’t officially given out specifics about its expected PCR changes. “CMS is considering a number of structural improvements in response to feedback received on the demonstration to date,” it says in a new question-and-answer set posted April 4.

But in its March 28 meeting with industry reps and providers, CMS officials shared some more detailed ideas about making big changes to the program, those reps say. Most notable of the revisions under consideration are making the demo program voluntary, and targeting the reviews to claims with certain higher-risk factors such as diagnoses or HHA performance history.

Timeline: “CMS will notify providers at least 30 days in advance via an update to this website of further developments related to the demonstration,” the agency says in its notice on the PCR site.

Don’t expect the pause and delay to be permanent, reps stress. NAHC believes agencies will see the revamped PCR details soon. “CMS believes it can come up with the revised program in 30 days,” NAHC’s VP for law William Dombi tells Eli. Then agencies will have 30 days from CMS’s resumption notice to prepare.

But CMS may give agencies longer than that 30-day timeline. When CMS paused the program back in September, it posted a notice of Florida’s new April 1 start date on Dec. 19, giving agencies in that state more than three-and-a-half months’ lead time.

But CMS may not even stick to the state order of implementation, it signals in the Q&As. “CMS … is exploring options to improve the program,” it says. “CMS will provide at least 30 days’ notice on its website prior to expanding the demonstration to FL or any other state.”

But sooner or later, “some type of PCR will eventually be enacted in Florida,” Lolley predicts. “It will continue until the problems with the F2F requirement have been addressed and/or providers can prove that they have the documentation in place to prove each and every patient they see meets the Medicare eligibility requirements.”

Bottom line: “Just like Illinois providers did,” first Florida and then other states’ agencies “will have to prove that not only the vast majority of patients seen are eligible for the home care benefit, but they can also provide adequate documentation to support that at any given moment,” Lolley expects.

Providers have expressed some frustration that the program’s pause in Illinois and delay in Florida came at the eleventh hour for Florida’s April 1 deadline. Lolley has seen bigger agencies particularly pour a lot of resources into PCR prep, including hiring new staff to handle the workload and changing internal processes. “Smaller providers have been trying to come up with a ‘solution’ without incurring a lot of additional cost,” he reports.

But that preparation isn’t all for naught, Markette points out. Claims scrutiny is increasing across the board. For example, Unified Program Integrity Contractor AdvanceMed “is auditing with intensity,” Markette observes. And it’s only a matter of time before the HHH Recovery Audit Contractor Performant Inc. gets home care topics approved and starts auditing accordingly, he adds.

Silver lining: The process of gearing up for PCR should have improved agencies’ documentation that is required by Medicare anyway. Florida agencies will get “the benefit of the preparation without the pain Illinois agencies have experienced,” Markette offers.

Note: See the notice at www.cms.gov/research-statistics-data-and-systems/monitoringprograms/medicare-ffs-compliance-programs/preclaim-review-initiatives/overview.html.