CMS Announces Delay in Florida Pre-Claim Review
September 20, 2016 02:08 PM
As reports of the chaos created by the Pre-Claim Review Demonstration (PCR) in Illinois continue to roll in, the Centers for Medicare & Medicaid Services (CMS) announced on Monday night, September 19, they will delay the start date in Florida by at least 30 days.
“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 stated on its website. “This education effort will focus on how to submit pre-claim review requests, documentation requirements, and common reasons for non-affirmation.”
Of course, NAHC warned CMS that the pre-claim review program “violates standards of reasonableness, economy, and efficiency” and that it is untargeted, with “high administrative costs and operational burdens” and “likely to create improper barriers to access to timely care.”
The PCR requires home health agencies (HHA) to submit claims to CMS contractors very early in the care process for an audit before the claim is submitted for payment. The demonstration began August 3 in Illinois and was scheduled to expand to Florida on October 1, but that is now delayed and will not begin until at least 30 days notice has been given. Unfortunately, the Illinois PCR Demonstration will continue, despite problems so numerous and troubling that CMS has decided to delay the Florida launch.
Texas was scheduled to begin PCR no earlier than December 1, with Michigan and Massachusetts following no earlier than January 1, 2017, but those will now be delayed, as well. No new start dates have been announced.
“We are delighted with this good news, but we don’t intend to relax,” said NAHC President Val Halamandaris. “We intend to press the issue until this ill-thought-out regulation is withdrawn.”
While this delay is welcome, it is certainly not sufficient. Illinois home care patients and HHAs continue to suffer under the PCR. The problems with the PCR Demonstration in Illinois are almost too numerous to mention here, but they include a 60-80 percent non-affirmed rate, with reasons for denials often contradictory, nonsensical or downright non-existent. One Illinois HHA reported that none of its claims submitted for PCR were approved by the Medicare Administrative Contractor (MAC). This is leading to HHAs withholding the start of care to patients until a favorable decision is received, resulting in longer hospital stays.
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.
Due in part to NAHC’s efforts, 116 bipartisan members of Congress signed a May 25, 2016 letter to 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 Bill Nelson (D-FL) and Marco Rubio (R-FL) to send a letter to CMS requesting the PCR demonstration not expand beyond Illinois.
In addition, 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). NAHC staffers met with the offices of Rep. Chris Murphy (D-18) and Rep. Ted Deutch (D-21) of Florida.
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. 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. NAHC will continue to insist the PCR Demonstration in Illinois be brought to an end and that its harm not be spread to other states.
The National Association for Home Care & Hospice (NAHC) is asking everyone to contact their members of their members of Congress and ask them to urge the Centers for Medicare & Medicaid Services (CMS) to rescind its prior authorization proposal for Medicare home health care services.
NAHC is committed to staying on this issue and will continue to make our case to members of Congress and CMS.