Home Health & Hospice Week

Postpayment review limits your documentation improvement options.

Don't expect the changes in the Pre-Claim Review program to significantly ease the program's burden. Many problems continue to accompany the proposed demonstration project.

For example: In the revised PCR proposal, the Centers for Medicare & Medicaid Services would allow home health agencies to use 100 percent prepay or postpay review (see story, p. 162 in pdf).

That doesn't really help matters, because most of the burden lies in gathering and furnishing to the Medicare Administrative Contractor reviewer the supporting documentation. Whether pre- or postpay, "agencies will still have to gather and submit all of the information," points out Sara Ratcliffe with the Illinois HomeCare & Hospice Council.

PCR's burden will persist "because the face-to-face/physician documentation requirement remains nebulous in clarity, inconsistent in its application by CMS/MACs/auditors, and labor-intensive for HHAs to obtain from physicians for reimbursement purposes," stresses the Home Care Association of Florida's Kyle Simon. "These systemic issues and failures are what should be addressed and corrected, rather than adding an additional burdensome process."

The choices between pre- or postpay review "are in line with a 'Hobson's Choice' in that all options are problematic," judges National Association for Home Care & Hospice President William Dombi. "Postpay review may be a slight improvement over prepay review in that the HHA will have money in hand for services rendered with potentially better documentation, given that the care would have been provided allowing for the documentation to show a clear picture on Medicare coverage," Dombi tells Eli. "However, postpay reviews can be haunted by 20-20 hindsight in circumstances where the patient does not show the anticipated improvement."

Even worse: The option for postpay review "would severely handicap any ability to obtain or improve the face-to-face documents in the record," warns consultant Joe Osentoski with QIRT in Troy, Michigan. Thus, "no agency in their right mind would risk taking the postpayment option," he believes. "So we are back to a repeat of prepayment reviews that hold up billing."

One good addition to the program is the specification that agencies that perform well will be able to get off review. "We had agencies that were getting between 90 percent to 100 percent affirmation rates within the first few months of PCR and were still required to submit 100 percent for PCR up until it was paused," Ratcliffe notes.

Many PCR Questions Remain

However, at press time CMS hadn't issued any specifics on what performance level would qualify HHAs to be removed from PCR - or on many other details. One outstanding question was exactly when PCR would go live in which states.

"Given our experience last time in just one state, it would be a monumental effort to bring all states on at one time," Ratcliffe tells Eli. Therefore, she expects PCR to roll out in a staggered fashion.

Since all the newly proposed demo states are served by the same MAC, Palmetto GBA, "I would be surprised if all the states could be implemented at once," Osentoski agrees. "They would have to be a staggered implementation with lessons learned from early states applied and supplied to later states."

Presumably, the industry will have at least until the notice comment period closes on July 30 before a PCR start date is announced.

Another area Osentoski would like to see CMS clarify is whether agencies subjected to PCR review will be excluded from other types of review. That is particularly important with the Targeted Probe & Educate program ramping up (see story, this page).

What's next: NAHC is "keeping all options open in terms of what we will be doing" in reaction to the PCR proposal, Dombi says. "We believe that there are much better alternatives than PCR to address any valid concerns on home health claims. The alternatives are much less burdensome and should be more effective."

Meanwhile, those who oppose the new program have 60 days to comment on the Federal Register notice. "By being ready to comment and fight this ... we can effect necessary change and allow CMS to know the hardships this proposal will cause," urges consulting firm Kornetti & Krafft Health Care Solutions in its member newsletter.