Illinois Congressional Delegation Asks CMS to Delay Pre-Claim Review
October 5, 2016 10:05 AM
The entire Illinois Congressional delegation signed a letter to Centers for Medicare and Medicaid Services (CMS) Acting Administrator Andy Slavitt, calling for a delay in the further implementation of the Pre-Claim Review Demonstration (PCR) in Illinois.
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 expand to four other big states later this year and early in 2017. However, the experiment in Illinois has gone so badly that last month CMS indefinitely delayed any expansion of PCR outside Illinois.
“Illinois’ experience under the PCRD has been alarmingly burdensome for home health providers, which is harming patient access to care,” reads the letter. “Presently, our understanding is that between 60-80 percent of PCRD submissions in Illinois are being non-affirmed” by Medicare contractors. “This non-affirmation rate is unacceptable, as patients are left without clarity on whether their medically necessary care will be covered.”
The letter notes that postponement of PCR expansion, but that is cold comfort to the home health agencies in Illinois struggling with a huge and time-consuming new paperwork burden, as well as serious cash flow problems caused by the abnormally high non-affirmation rate. To say nothing of the patients who urgently require care, but now have no idea if they will receive it because it may not be covered by Medicare.
Therefore, the entire Illinois delegation to Congress urges “CMS to immediately grant the state of Illinois the same PCRD delay that your agency has provided to Florida, Massachusetts, Michigan and Texas, until education and guidance” for home health providers, patients and Medicare contractors is improved. “If the lessons from Illinois prove that PCRD is not adequately developed for implementation in those states, then our constituents and provider organizations deserve the same consideration.
NAHC whole-heartedly agrees. NAHC advocates have spent many hours working with lawmakers and their offices in recent months to alter or end pre-claim review and this bill is only the latest evidence of that hard work. 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.
NAHC worked closely with members of Congress on the Pre-Claim Undermines Seniors’ Health (PUSH) Act, which would impose a one year moratorium on PCR and require CMS to report to Congress on the impact of the project on patients, home health agencies, physicians, and Medicare spending.
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 have also met with and contacted numerous other offices.
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 Congress and urge them to stand with the 3.5 million Americans who depend on home health services AND support the Pre-Claim Undermines Seniors’ Health (PUSH) Act.
NAHC is committed to staying on this issue and will continue to make the common-sense case against pre-claim review to Congress and the CMS.