NAHC Storms Capitol Hill to Stop Pre-Claim Chaos
September 16, 2016 04:03 PM
As NAHC and home health agencies (HHA) warned, the Pre-Claim Review Demonstration (PCR) begun in Illinois on August 3, 2016 by the Centers for Medicare & Medicaid (CMS) is creating chaos for almost 200,000 seniors across the state and the providers who serve them.
NAHC and its members have not been taking this laying down. NAHC staffers accompanied Sheila Guither, Sarah Ratcliffe and Micah Roderick – president, executive director and director of public affairs, respectively, for the Illinois HomeCare and Hospice Council on a series of visits to lawmakers on Capitol Hill to build support for opposition to PCR. They met with members of Congress from the Illinois delegation, including Mike Quigley (D-5), Peter Roskam (R-6), Tammy Duckworth (D-8), Jan Schakowsky (D-9), Bob Dold (R-10), Randy Hultgren (R-14), Adam Kinzinger (R-16), Cheri Bustos (D-17), Darin LaHood (R-18), and Senator Mark Kirk (R). In addition, NAHC staffers met with the office of Rep. Chris Murphy (D-18) of Florida.
Members of Congress are being urged to weigh in with CMS and urge it to cancel PCR or, at the very least, delay it for some time until its many problems can be worked out. Those problems are almost too numerous to list here, but they include a 60-80 percent non-affirmed rate, with reasons for denials often contradictory, nonsensical or downright non-existent. In one case, an agency submitted documentation for PCR and it was non-affirmed. Thinking the information provided was complete, the agency re-submitted the documents. This time the documents were confirmed, but with no explanation for the prior denial or why the very same documents were affirmed the second time they were submitted.
What’s worse, many Illinois agencies have received non-affirmations for physical therapy for whole knee replacements, with the Medicare Administrative Contractors [MAC] deeming therapy medically unnecessary. This is leading to HHAs withholding the start of care to patients until a favorable decision is received, resulting in longer hospital stays. This, of course, defeats the purpose of PCR, which is to eliminate unnecessary cost. An average day in an Illinois hospital costs $2025, but a home health visit costs a mere $168, so every single day a patient spends in a hospital when he or she should and could be receiving treatment at home, is a significant unnecessary cost. The Pre-Claim Review Demonstration is defeating its own purpose!
Other problems include the time-consuming new paperwork burden, an inefficient electronic system that cannot process the documentation, physician unfamiliarity with what is needed for PCR due to poor education from CMS and the MACs, and considerable cash flow problems at agencies. At least one Illinois HHA has closed due to PCR and others may soon follow. A rural hospital is on the verge of closing its HHA program. These closures will cause patients to go without the care they need and provider jobs will be lost.
None of this is what patients want. A recent national poll of voters over age 65 found that 83 percent of U.S. seniors believe doctors should be able to prescribe medications and treatments for their patients without government interference, yet MACs and the CMS are now contradicting doctors and stepping between physicians and their patients.
If PCR was created to root out fraud and abuse, it was poorly designed. The Office of Inspector General (OIG) has identified characteristics commonly found in fraud cases, so CMS should concentrate its resources on pursuing those outliers, instead of punishing hard-working and law-abiding home health agencies and their patients.
As if all this were not bad enough, what’s happening in Illinois will soon be spreading to Florida, Texas, Massachusetts and Michigan. There are 3.5 million homebound Medicare beneficiaries who depend on the Medicare home health benefit and they – and their providers – all stand to be negatively affected if PCR becomes our new national standard.
Due in part to NAHC’s efforts, 116 bipartisan members of Congress signed a May 25, 2016 letterto CMS calling for the withdrawal of the original prior-authorization proposal. In addition, Rep. Tom Price (R-GA), whom NAHC has worked closely with on this issue, asked at a September 7 House Ways and Means subcommittee hearing on Medicare if the country would be “aided by a delay in this demonstration so CMS can get their act together?” NAHC also worked with Senators Nelson (D-FL) and Rubio (R-FL) to send a letter to CMS requesting the PCR demonstration not expand beyond Illinois.
NAHC and its members are determined to find a superior alternative to PCR. It is possible to root out the fraud we all deplore without punishing patients and home health agencies. NAHC is committed to staying on this issue and will continue to make our case to members of Congress and CMS.
Stay tuned to NAHC Report on Monday when we will feature videos from home care patients and providers in Illinois discussing how they are dealing with the pre-claim review chaos. It will open your eyes and, we hope, prompt you to take action. Look out for it on Monday!
For even more on this issue, NAHC Report recommends this superb opinion piece written by Illinois HomeCare & Hospice Council President Sheila Guither and published in the State Journal-Register.