Home Health & Hospice Week

Start self-auditing F2F now.

Nearly half the HHAs in the nation will undergo 100 percent pre-claim review as the PCR demo rolls out between now and January. And many more are predicted to go under expanded PCR or similar review initiatives in the near future as well.

Such review may make or break cashstrapped HHAs. Make sure you weather the PCR storm with this expert advice:

1. Understand PCR requirements. Particularly for agencies in Illinois, which will see PCR take effect in a few short weeks, it will be a challenge to get a handle on the pre-claim review requirements before the demo’s implementation. But agencies must get up to speed on what they need to submit under PCR, from the technical components to the documentation content, notes Chicago-based regulatory consultant Rebecca Friedman Zuber.

Review the task list issued by Palmetto and CGS (see box, p. 206) to help you decide what to submit, advises attorney Adam Bird with Liles Parker in Washington, D.C. The list “will ideally serve as some solid guidance for agencies trying to discern what the pre-claim reviewers want to see,” Bird tells Eli.

Stay tuned: But Bird hopes the MACs will issue more details about exactly what documentation to submit. And Friedman Zuber would like to see some of the overly burdensome components of the “tasks” eliminated. Keep an eye on your MAC’s website for emerging specifics.

2. Educate physicians. It’s hard to say who will dislike this demonstration more — HHAs or referring physicians. But docs who want their patients to receive home care will have to jump through the Centers for Medicare & Medicaid Services’ hoops. Help them learn exactly what those hoops are with educational sessions focused on the face-to-face requirement, Bird counsels. “Conduct in-services with … physician referral sources now regarding timeliness and content requirements of face-to-face encounter records,” he recommends.

“We have to figure out a way to enlist [docs] on our side,” Friedman Zuber exhorts. “Prepare them for the letter and training they will be getting from CMS and their MAC on this demo.”

Last resort: “If some physicians consistently refuse to document adequate or timely face-toface encounters, agencies should consider no longer accepting referrals from those physicians,” Bird says.

3. Educate your own staff. Referring physicians aren’t the only ones who CMS will contact under the demo. Patients will also receive letters notifying them of the affirmed or not-affirmed decision on the pre-claim review request.

“Prepare your clinicians to answer questions coming from patients,” Friedman Zuber advises. Patients “will be getting a letter from CMS explaining this program and will be confused.”

4. Assign PCR responsibilities. The logistics of complying with PCR aren’t likely to be easy. Figure out how you will operate under the demo and who will be responsible for what. “Look critically at your processes and recognize that this process cannot be handled by clerical staff alone, unless they are very experienced and knowledgeable,” Friedman Zuber says. “Professional review of each submission is really important, at least initially.”

5. Anticipate lookback. The PCR program may start Aug. 1 (or later in other states), but claims for recertification episodes will require F2F from the initial episode, Bird reminds agencies. “For this reason, providers should not wait to begin reviewing their documentation and searching for ways to improve it,” he urges. “We strongly recommend that providers initiate internal auditing protocols now, irrespective of when the demonstration may begin in their state.”

6. Gear up for eServices. Palmetto wants agencies to use its eServices app to electronically submit pre claim review requests, for good reason (see story, p. 206). Find out how with the step-bystep tutorial in the MAC’s workshop presentation at www.palmettogba.com/Palmetto/Providers.Nsf/files/Workshop_Home_Health_PCR_Workshop_Series.pdf/$File/Workshop_Home_Health_PCR_Workshop_Series.pdf.

Key: “Investigate how you are going to produce the documents required in PDF format,” Friedman Zuber emphasizes. This could be a major resource- drain if you can’t do it quickly and efficiently.

7. Use PCR. After the first three months of implementation, the claims system will dock HHAs’ reimbursement 25 percent for claims that don’t first go through the PCR process. And that’s even though the non-PCR claim will get automatically stopped for prepayment review anyway.

“We recommend that agencies always utilize the pre-claim review process,” Bird says. “The 25 percent payment reduction is too steep a penalty for non-compliance.”

8. Plan for revenue disruption. Even the most prepared and diligent of HHAs are likely to see hiccups as they get the hang of PCR. “Pre-claim review will likely disrupt … ordinary revenue cycles,” Bird cautions. “Begin taking appropriate action.”