Home Health’s Pre-Claim Review Are You Affirmative or Non-Affirmative?

By: Melody Dizon

 

To say the least, the last four weeks of the new Home Health’s Medicare’s Pre Claim Review (PCR) implementation in Illinois, being the first state to pilot the program, is nothing but plenty of sleepless nights, anxietyfilled days, panic–stricken office hours or computer-dazed look, in other words, CHAOTIC.

My office alone, we find ourselves digging into more paperwork, chasing clinical documents, printing unnecessary paper trail, driving back and forth to doctors’ offices, waiting and more waiting for clinicians’ signatures, holding more and more seminars, pounding on staffs for regulatory compliances, putting in more hours, squeezing in another hour to the only 24 hours all of us are given, and if that were not enough, cell phones, ipads, faxes, laptops and computers are always in sight and sounding off like crazy, as if they are also on overtime.

Most definitely, this has been one of the most, if not the most stressful, time in the home health industry. Everyone is just working so hard to a system, to a new rule, that is not so clear to everybody yet. You can only imagine the frustrations, especially when you hear the words: NON – AFFIRMATIVE. It is as if your whole world crumbled, with all the extra effort you put into it. So, you guess it right, I am not alone in this so any minute now, my phone buzzes off, because somebody needs to ask something which I don’t know the answer to as well.

To say it bluntly, from National Association of Home Care and Hospice (NAHC’s) Vice President of Law, Bill Dombi, “It is a complete mess.” Their forecast of the magnitude and effect of the PCR will be to the Home Health (HH) community is grave and is as close to accurate. The Medicare Administrative Contractor (MAC) along with Center for Medicare Services (CMS) Central Office have shown that preparation is falling far short of what is needed to handle simple tasks, like setting up a reliable documentation submission system.

Two U.S. Florida Senators have said that, “We remain concerned that this demonstration may restrict beneficiary access to timely services, divert clinical resources to paperwork management, and incur high administrative costs. Endless reports from Home Health Agencies (HHAs) with respect to documents submitted electronically are: either non-receipt of the documents, hours spent for each submission, meaning per chart, illegible documents, inability to save a PCR, and finish at a later time. But the most serious PCR problem goes beyond the handling of submitted documentation. Regarded as the worst regulation yet in PPS (prospective payment system) era, a discussion sponsored by NAHC and the (IHCC) Illinois Home Care Council, with over 100 home health companies who participated, “It has become clear that the MAC has rejected 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 “negative chilling effect” among veteran home health agencies across the state”. There is 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” Summary of their discussion:

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 to help correct alleged documentation deficiencies, non affirmatives as “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.

Based on their findings, NAHC and IHCC developed a 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 surfaced 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. Ongoing HHA communications. Each Thursday, NAHC and the Illinois Council are holding Web-based “chat rooms” for HHAs to present upto- 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

Bottom line for me:

Already, pre-claim is taking a toll on the agency, which at this point may have to hire an extra person, if they haven’t already, just to push the necessary paperwork to be in compliance. Support NAHC’s plan of action.

“It is a cause of concern that the demonstration may fall short and may not go far enough and it may fail to protect patients from potential harm inherent with pre-claim review, including confusion, delays and service interruptions in care for a vulnerable patient population.

It is also a cause of concern that CMS may be slow in following notice-and-comment standards for obtaining and responding to input from those immediately affected by the demonstration until it may be too late.”

Right now, CMS hasn’t clearly defined what documentation will be necessary to submit for review prior to a claim and the agency needs to offer further guidance and their definition of why a service is not deemed necessary.

As a provider and business owner, there will be continuous cash flow issues because of high non-affirmation rates, if a provider submits a claim without going through the pre-claim review after the first three months of the demonstration, and the claim is determined payable, there will be a 25% reduction in the full claim amount.

The financial aspect is crucial, even without considering potential deductions in Medicare payments. The administrative side of compliance could prove costly, and might take funds away from other critical aspects of business. Be prepared.

Good luck to us all home health agencies! We all need support. Be part of a group. Contact Association of Certified Home Health Agencies in Illinois. (773) 233-4888

Your Advocate, UNCHAINED MELODY

A recent meeting held where Illinois home healthcare owners unite for the issue of abolishing PCR (Pre-Claim Review) in Illinois.