Home Health & Hospice Week

GAO wants Pre-Claim Review to resume.

Medicare is revealing more details about its resurrected Pre-Claim Review demonstration project, which it’s now calling the “Review Choice Demonstration.” But many specifics remain cloudy.

One of the most pressing questions for home health agencies in the five states the Centers for Medicare & Medicaid Services identified for the PCR/RCD demo was the implementation schedule. In its May 31 Federal Register notice about the demo, CMS merely said that it was proposing “initially implementing the demonstration in Illinois, Ohio, North Carolina, Florida, and Texas with the option to expand to other states in the Palmetto/JM jurisdiction.”

In a PCR/RCD question-and-answer set released May 31, CMS clarified that it would group the five demo states into three stages for implementation. “CMS will stagger implementation of the Demonstration, beginning with the state of Illinois, then expanding to Ohio and North Carolina, and later to Texas and Florida,” the Q&A say.

CMS also specifies that “the revised demonstration will begin no earlier than October 1, 2018” and the demo will last five years.

However, affected HHAs require more specifics than that, maintains William Dombi with the National Association for Home Care & Hospice. “We need the timetable that CMS expects to use to roll out RCD in the various states,” Dombi tells Eli.

GAO Is Not On Your Side

Many home care industry members were taken by surprise when CMS announced its intention to bring back PCR. “It seems like pre-claim review is becoming the Lazarus of the home care industry,” observes Washington, D.C.-based healthcare attorney Elizabeth Hogue.

CMS’s notice came after an April Government Accountability Office report recommending that CMS resume “the paused home health services demonstration.” The GAO also wants CMS to identify “new opportunities for expanding prior authorization to additional items and services with high unnecessary utilization and high improper payment rates,” and take other prior authorization-boosting steps.

Perhaps in anticipation of industry opposition, CMS included some preventive justification for its resurrection of the much-reviled program. “This revised demonstration would help assist in developing improved procedures for the identification, investigation, and prosecution of potential Medicare fraud,” CMS says. “The Demonstration furthers CMS’ efforts to protect the Medicare Trust Funds from improper payments and to reduce Medicare appeals.”

The agency also downplays any potential access problems caused by the demo. “The revised demonstration should have minimal effect on beneficiaries and does not alter the Medicare home health benefit,” CMS maintains in the Q&As. “Under the pre-claim option, the pre-claim review request can occur after home health services have started.” CMS spells out the difference between prior authorization and RCD. “With pre-claim review, services can begin,” the agency says.

And CMS plays up the changes it makes to the demo. “CMS is revising the Demonstration to incorporate more flexibility and choice for providers, as well as risk-based changes to reward providers who show compliance with Medicare home health policies,” it says.

But home care providers and their advocates say the changes are mostly window dressing that don’t mitigate the program’s burden and other shortcomings (see Eli’s HCW, Vol. XXVII, No. 22).

Original PCR Caused Cash Flow Delays, Access Problems

Chief among RCD’s flaws is its ineffectiveness, particularly in comparison to its added workload level. “I am unclear how pre-claim review really addresses the issue of fraud and abuse,” Hogue contends. “The MAC gets an initial ‘snapshot’ of the patient’s condition, which may meet applicable criteria, but the bulk of the information about any episode isn’t going to undergo pre-claim review.”

Plus: “Just because an agency achieves a certain rate of ‘compliance’ and is removed from review doesn’t mean that all subsequent claims will meet applicable requirements,” Hogue adds. “I just don’t see the real value.”

During PCR’s previous iteration, it “had a sizable impact on patients and providers in the state of Illinois, damaging cash flow and causing delay in treatment in some cases,” NAHC warns in its member newsletter.

While CMS touts RCD “as a choice of options for home health agencies, the options presented are two with increased paperwork burdens and one that would financially cripple a home health agency with a 25 percent payment reduction,” Dombi protests in the newsletter. “We certainly do not want to see nurses, therapists, and home care personnel spending their days chasing down paperwork at the expense of patient care.”

Unfair: “No other health care sector is forced to submit every care claim for review or face a punishing 25 percent pay cut,” NAHC points out.

“It is important to remember that when PCR was halted originally it did not find evidence of unnecessary care or services provided that were not meant to be covered,” NAHC insists. “Instead, PCR merely found correctable documentation issues, a problem that was fixed and was hardly worth the pain inflicted on home health providers and patients.”

How Will 90% Option Work?

While the industry gears up to oppose the demo (see story, this page), it also is awaiting further details about CMS’s plan for the program. “Additional information will be released in the coming months,” CMS pledges in the Q&As.

The list of outstanding questions about RCD is long, Dombi tells Eli. In addition to the rollout timetable, HHAs need to know “the specifics on how the 90 percent performance exemption will work, how CMS intends to provide training to HHAs on RCD best practices, what CMS will be doing about staffing resources at Palmetto GBA to handle the new workload, what plan CMS has to conduct real time analyses of what is happening with RCD, and what oversight CMS will conduct to prevent harm to patients that could be triggered by review errors,” he notes.

Note: A link to the Q&As is in the “Downloads” box at www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Choice-Demonstration/Review-Choice-Demonstration-for-Home-Health-Services.html.