Home Health & Hospice Week

Administrative burden is program’s biggest fault.

It’s no joke: The much-reviled Pre-Claim Review demonstration program is set to begin in its second state on April Fool’s Day.

The Centers for Medicare & Medicaid Services “will expand the Pre-Claim Review Demonstration for Home Health Services to Florida for services that begin on or after April 1, 2017,” CMS posted on its PCR website Dec. 19.

Background: CMS launched PCR in Illinois on Aug. 3, and had scheduled start dates for Florida on Oct. 1, Texas on Dec. 1, and Massachusetts and Michigan on Jan. 1. But after some major PCR difficulties — and pressure from some high-profile lawmakers, among others — CMS scuttled the remaining four states’ start dates indefinitely (see Eli’s HCW, Vol. XXV, No. 35).

PCR continues to draw heavy fire from the industry and its supporters on Capitol Hill. Attorney Robert Markette Jr. with Hall Render in Indianapolis says he was surprised when CMS pushed forward with the program expansion, due to the widespread criticism.

But even during the hold, CMS and its contractors had continued furnishing education about the PCR demonstration in Florida and Texas (see Eli’s HCW, Vol. XXV, No. 37). William Dombi, VP for law with the National Association for Home Care & Hospice, says the expansion was expected.

What was not expected, however, was a relatively long lead time for its implementation.

“CMS had promised at least 30 days” between the announcement and PCR’s implementation, “so getting 90+ was a surprise,” Dombi tells Eli.

Affirmation Rate Nears 90%

Quickly on the heels of its PCR expansion announcement, CMS released data through week 20 of the demonstration. As of Dec. 17, “89.4 percent of pre-claim review requests in Illinois received provisional affirmation, including both fully affirmed or partially affirmed decisions,” CMS said in a Dec. 22 post to its PCR website.

In a simultaneously released document delving further into the statistics, CMS revealed that 85.1 percent of requests were fully affirmed, leaving 4.3 percent partially affirmed.

Remember: Partial affirmations are partial denials, Markette stresses. If 90 percent of claims are accepted, that’s still equivalent to a 10 percent rate cut. Not many agencies can sustain that kind of steep reimbursement decrease over time.

The figure may be misleading because it doesn’t spell out how many submissions are required for a request before it receives affirmation, Markette points out.

And the affirmation rate may be artificially high because home health agencies aren’t yet submitting their full volume, industry experts caution. “We still have no data on how many agencies are submitting and how many are up to submitting all their episodes,” reports Chicago-based regulatory consultant Rebecca Friedman Zuber, who works with the Illinois Homecare & Hospice Council. “We think that the majority of IHHC members are submitting 100 percent now, but we know that some are still only submitting 50 to 60 percent because of volume.”

“There are significant backlogs of claims to be done,” contends Joy Cameron with the Visiting Nurse Associations of America. “With the 25 percent payment penalty for submitting outside of the PCRD process, the backlogs continue to grow,” Cameron tells Eli.

Early stats released by CMS comparing Requests for Anticipated Payments versus PCR submissions suggested that perhaps only a quarter of claims were going through the PCR process, Markette recalls. As that number increases to full volume, expect to see affirmation stats drop, he predicts.

PCR Burden Crushes Agencies

CMS seems to believe that as agencies become familiar with the PCR process, they will be able to catch up on submitting PCR requests. But that just won’t be possible due to the overwhelming burden that the program places on agencies.

“One agency I spoke with has a full-time LPN focusing on just these claims and she is completing eight to 10 claims a day,” Cameron reports. “Regardless of the familiarity with the process, this is still … extremely time consuming.”

CMS and its contractors may claim that the PCR submission process takes only a short period of time. But that calculation doesn’t take into account the time spent gathering the supporting documentation that must be submitted, Markette stresses. What should be a 15-minute data entry process becomes over an hour of documentation-gathering — or more, he says. And that’s for every single claim.

Most agencies must hire at least one FTE to handle the PCR process, if not more. “It’s a huge amount of manpower,” he observes.

“The administrative burden is immense,” Friedman Zuber maintains. “It is like having an ADR on every episode. Most agencies now have staff who do nothing but PCR.”

Drain: “For many of the smaller agencies without the luxury of staff devoted to the (PCR) process, it has made doing other important functions like quality improvement and day-to-day management very difficult,” Friedman Zuber says.

The burden is even larger than agencies first thought, Friedman Zuber adds. “Our members are routinely submitting nursing notes, home health aide assignment sheets and visit notes, therapy assessments and visit notes, to demonstrate that services are being provided as ordered in the plan of care and at a level that is covered by Medicare,” she says.

“This seems to be above and beyond what was originally intended, but we have bitten the bullet and advise our members to submit these documents to avoid re-submissions.”

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