Medicare Compliance & Reimbursement

Medicare indicates need for more education.

While Illinois Home health agencies are still struggling under Medicare’s Pre-Claim Review demonstration, agencies in Florida, Texas, Massachusetts, and Michigan are getting some relief as launch dates are put on hold.

The Centers for Medicare & Medicaid

Services has announced an indefinite delay to PCR’s roll-out in the four states, which were scheduled for demo launches Oct. 1 (Florida), Dec. 1 (Texas), and Jan. 1.

Background: CMS launched the PCR program in Illinois on Aug. 3, and soon thereafter complaints about the program came rolling in. Criticisms ranged from technical submission glitches to lack of physician education on proper documentation to inconsistent review determinations.

Trade groups reported non-affirmation rates reaching 80 percent, although HHH Medicare Administrative Contractor Palmetto GBA said it was seeing a rate closer to 60 percent.

Update: Now a CMS rep also says that the 80 percent denial figure “is inconsistent with what CMS is seeing based on early data.” However, the agency doesn’t offer an alternative figure. “CMS is reviewing initial data regarding the Pre-Claim Review Demonstration for Home Health Services and plans to release information on the affirmation rate once the necessary data have been collected,” the CMS spokesperson says.

In addition to complaining directly to CMS and MACs after PCR’s launch, HHAs and their representatives quickly appealed to their elected officials to intercede on their behalf. Members of Congress reached out to CMS informally, and letters opposing the program were sent members of the U.S. Senate and House.

Industry Declares Lobbying Victory, But Only Partially

After the intense lobbying effort, CMS on Sept. 19 announced an indefinite delay to PCR’s launch in the remaining four demonstration states.

“Based on early information from Illinois, CMS believes additional education efforts will be helpful before expansion of the demonstration to other states; therefore, we will not move forward with initiating the demonstration in Florida in October,” the agency says on its PCR website.

Due to the need for education, “CMS will therefore take additional time prior to expanding to other states,” it says.

Stay tuned: “The start dates for Florida, Texas, Michigan, and Massachusetts have not been announced,” CMS notes. “However, CMS will provide at least 30 days’ notice on this website prior to beginning in any state. CMS continues to expect a staggered start, beginning with Florida.”

Success: “Without the countless contacts and visits to Capitol Hill, Michigan would be implementing this program January 1,” cheers Michigan HomeCare and Hospice Association head Barry Cargill in a letter to members. “This is no small feat and we need to enjoy our victories,” Cargill says in the letter.

Home Care Association of Florida head Bobby Lolley says he is “enormously pleased” with the delay. “It was simply too much, being tried too quickly,” Lolley notes. “Providers were not ready, ordering physicians had not been educated, and the MACs themselves stated they were refining the actual process week by week.”

While agency reps agree that the delay is good news, they are unanimous in saying that it doesn’t go far enough. “CR should be fully rescinded in Illinois and not started elsewhere,” National Association for Home Care & Hospice VP for law William Dombi says. “CMS has enough information already to develop an effective correction action plan that does not involve massive untargeted pre-claim reviews.”

The Visiting Nurse Associations of America believes “that a pause is not enough,” VNAA’s Joy Cameron says. “We have been actively advocating Congress and CMS to suspend and eliminate the Pre-Claim Review demonstration. Also, this pause does not help agencies and patients in Illinois who are still in the midst of Pre-Claim Review. We are worried that the confusion caused by ‘non-affirmed’ letters going to patients could lead to them unnecessarily declining care that they need.”

Timing uncertain: While the relief is welcome, the uncertainty of the reprieve’s length makes demo state agencies nervous. And state trade group reps aren’t counting on a total elimination.

While PCR “won’t be happening on January 1, as planned, Pre-Claim Review will likely be implemented at some point,” Cargill warns in the letter.

“No matter how much I wish that would be true, I don’t think [PCR] will be eliminated,” Lolley laments.

NAHC and VNAA pledge to keep hammering away at CMS and elected representatives to get the program scrapped altogether. “VNAA is hopeful that this is the first step in eliminating the Pre-Claim Review demonstration,” Cameron says.

“NAHC and its members are determined to find a superior alternative to PCR,” the trade group says in its member newsletter. “It is possible to root out the fraud we all deplore without punishing patients and home health agencies.”

Note: See the delay announcement and watch for further updates at www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Pre-Claim-Review-Initiatives/Overview.html.