Medicare Home Health Pre-claim Review Project a “Complete Mess”
September 1, 2016 09:45 AM
Forecasts of dire consequences stemming from the recently initiated Medicare home health pre-claim review (PCR) project in Illinois are turning out to be highly accurate. Medicare Administrative Contractor (MAC) PGBA along with CMS Central Office have shown that preparation is falling far short of what is needed to handle simple tasks, such as setting up a reliable documentation submission system. Endless reports of the MAC losing documents submitted electronically led to a CMS recommendation that home health agencies (HHAs) resort to antiquated fax submissions. Those fax submissions faired no better.
“It is a complete mess,” explained Bill Dombi. NAHC’s Vice President for Law. “That is the result that we all predicted given the magnitude of the undertaking that increased the MAC’s claim review workload 40-50 times of its normal volume,” he added.
HHAs report the following with respect to document submissions:
“it is taking us an hour for each submission”
“documents go through, but PGBA says they are illegible when received”
“can not start a PCR, save and finish later”
However, the most serious PCR problems go beyond the handling of submitted documentation. In a “Chat Room” discussion sponsored by NAHC and the Illinois Home Care Council, with over 100 home health companies participating, it has become clear that the MAC will reject a high proportion of pre-claim reviews on the basis that the patient is not homebound or that the care is not necessary. These “on the merits” decisions are creating a serious “chilling effect” among veteran home health agencies across the state. With chat room reports of an 80% rejection rate, agency executives indicate that they plan to withhold the start of care until a favorable pre-claim review decision is issued. It can be expected that access to care problems will escalate in the very short term unless CMS and the MAC reverse course quickly. Comments such as the following are growing:
“a local hospital based agency who decided, in part, to close its doors rather than participate in PCR”
“our experience is a 4-7 days delay in service”
“we are also getting non-affirmations on knee replacements”
The high rate of rejection is compounded by the uninformative reasons given by the MAC in the rejection notice. While the primary intent of the project is the help correct alleged documentation deficiencies, conclusory statements such as the “patient is not homebound” offer no guidance to home health agencies seeking to take corrective actions. However, it may not be possible for the MAC to provide better guidance, as the HHAs report that the rejected claims involve patients with a clear homebound status and need for the physician-ordered care.
PLAN of ACTION
As the PCR tragedy continues to unfold, NAHC is taking the following steps designed to suspend PCR in Illinois and prevent its expansion into the other four targeted states, Florida (October 1); Texas (November 1); and Massachusetts and Michigan (January 1):
1. Heightened congressional PCR advocacy on our behalf. At this point, numerous congressional officials have communicated their concerns to CMS. Another round of bipartisan, bicameral action is in process as Congress returns to work next week. The threat to care access that have surface in actuality rather than theory will drive that engagement. With Congress returning to work, the option of a legislative fix exists, albeit with great difficulty in a year focused on the elections and backlogged work on the budget.
2. Enlistment of the patient advocacy community. As a member of the Leadership Council of Aging Organizations, NAHC has reached out to numerous patient advocacy groups to enlist their support in rescinding PCR. This is a highly patient impacting project, as HHAs begin to withhold care as a result of PCR rejections.
3. Development of real-time impact data. NAHC and the Illinois Council have developed a PCR data toll that is in use by the Illinois home health agencies, providing uniform real-time data on the business and patient impact of PCR. The tool’s use will be expanded to the other affected states beginning in October if PCR is not rescinded.
4. On-going HHA communications. Each Thursday, NAHC and the Illinois Council are holding Web-based “chat rooms” for HHAs to present up-to-the-minute PCR experiences, problems, and potential solutions. NAHC and the Illinois Council will issue notices of the upcoming chat sessions.
5. Open lines of communication with CMS.Medicare officials have established a weekly conference call discussion with NAHC in order to stem any operational problems and gain an understanding of HHA/patient impact. NAHC has also been in communication with the CMS Office of the Administrator with the request to suspend the project.
6. Development of a lawsuit challenging the project’s validity and authority.Litigation is always a last resort. With respect to PCR, litigation needs support of evidence of harmful impact. Unfortunately, that means that any lawsuit must wait for the harm to surface in order to present a compelling case in court. With PCR, that harm is just beginning to emerge, as it has taken a few weeks for HHAs and the MAC to reach the first stage of PCR determinations.
Stayed tuned to NAHC report for further updates on PCR. Please send information about PCR experiences and difficulties to PCR@nahc.org.