Home Health & Hospice Week

You can’t afford to wait and see — prepare now.

As pre-claim review gets off to a slow start in Illinois, home health agencies around the nation are gearing up their own operations for the 100 percent pre-pay review program to begin.

Recap: After some Paperwork Reduction Act-related confusion, the Centers for Medicare & Medicaid Services launched PCR in Illinois Aug. 3 (see Eli’s HCW, Vol. XXV, No. 30). Under the program, HHAs submit a Request for Anticipated Payment (RAP), then a pre-claim review request including all documentation needed to support the claim (including the face-to-face physician visit note), and then the HHH Medicare Administrative Contractor will issue a decision on the request in a goal of 10 business days.

A week after the launch date, Palmetto GBA had received “less than 10” PCR requests, a representative for the HHH Medicare Administrative Contractor told Eli Aug. 4. At press time, “the number of submittal requests continues to increase,” the rep added a week later.

Remember: “PCR is voluntary for the first three months of the demonstration in each participating state,” the Palmetto source reminds. HHAs have a while before they must comply.

Extensive Documentation Requirements Slow PCR Process

The trickle of requests at PCR’s start is not a surprise. “An HHA cannot submit the pre-payment review request until it has all of the documentation,” notes attorney Robert Markette Jr. with Hall Render in Indianapolis. “It will take a while for the volume to build because of all of the signed documentation that is required,” notes Chicago-based regulatory consultant

Rebecca Friedman Zuber. “They want signed and dated plans of care, which can take quite a while. Plus we have to get acceptable documentation from the physicians supporting homebound status and need for skilled care.”

Remember: “The 10-day clock cannot start until you have all of this documentation,” Markette notes. The best-case scenario for amassing the necessary documentation is likely a week, he believes.

As with the number of requests, the number of decisions is also small, although Palmetto has not divulged a specific figure. At press time, Illinois HHAs were just starting to report both affirming and non-affirming decisions — along with plenty of frustrations ranging from exorbitant submission preparation times to vague non-affirmed determinations.

Expect Pre-Claim Review To Grow

While the program has launched in Illinois, HHAs and their reps in other PCR demonstration states are working to get the program suspended or halted altogether before it hits them. For example, the Texas Association for Home Care & Hospice urged its members in a July 28 Action Alert to contact their representatives in Congress, asking them to try to stop the PCR demo in the state, which is scheduled to begin Dec. 1.

CMS has forged ahead with the demo “despite receiving a Congressional letter supported by over 110 Members of Congress, numerous stakeholder comment letters and a state delegation letter led by TAHC&H,” the trade group protested. The program has “serious problems” and “there are no clear assurances that CMS contractors have the capacity or the ability to administer such a complex and large change to how patient care and access is currently provided,” TAHC said in the Alert.

However, Palmetto “continues to process the Pre-Claim Review submittal requests within the timeliness requirements,” the MAC rep says.

You shouldn’t hold your breath waiting for a reprieve, experts warn. “Make no mistake, pre-claim review is not going away,” said clinical consultant Lista Clark with Healthcare Provider So-lutions in Nashville, Tenn., in a June blog post. Not only will the demo states proceed on schedule, but PCR “will likely go into effect for all states in the near future,” Clark predicted.

“Even if your agency is not in one of the chosen states, you cannot afford to ‘wait and see,’” Clark warned. “A focus on quality and compliance, including pre-claim compliance, must be your priority.”

“This demonstration appears to be extremely problematic for providers,” Markette stresses. “It will likely lead to delays in payment and a significant percentage of claims not being paid.”

Don’t wait: “Providers in the demonstration states need to be working very diligently now to prepare in order to minimize the impact once the demonstration goes live,” Markette urges.