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Surviving the Pre-Claim Review & Beyond
by Altamash Mir
Everyone associated with the Home Health Care industry agrees that 2016 was a rough year! As the news came out in mid-June 2016 that Pre-Claim Review was to be the new rule, agency owners, administrators & clinicians were certain that the Home Health business model as it existed for small businesses was to surely die & they entered what’s known in clinical circles as the Kübler-Ross model, or the five stages of grief.
Denial – Home Health Agency Owners, administrators & other staff were heard across the board proclaiming that “it is not possible at all that CMS would implement such a harsh rule on us AND only give us 45 days to prepare!!!”. Most believed that either NAHC or Congress will intervene & cancel the Pre-Claim Review Demonstration and it would hinder in the care being provided to seniors.
Anger – As the August 1st, 2016 deadline crept up, Home Health Agencies collaborated with peers & demonstrated their displeasure with the upcoming changes in the system. They called upon & wrote letters to their Congressmen, participated in public protests, called upon their state associations to act & formulate strategies to counter the new law. Some went too far in being angry at CMS and publicly stated that since Urban Illinois is mostly minorities, this new rule is created to take services away from them.
Bargaining – By mid July 2016, Agency owners were in complete disarray! From trying to open up prospective clients before the August 1st, 2016 deadline, to calling up Palmetto GBA & asking for a few extra days to be given to them, since their patients hadn’t been discharged from facilities. Obviously, as expected, none of these requests were fruitful and agencies had to comply with the said new rules.
Depression – As August 1st, 2016 crept up, agency owners became certain that their clinical staff would not comply with the strict time sensitive guidelines laid down by CMS & their agencies would collapse financially. Many agency owners decided that it’s probably better to either sell their agencies or shut down.
Acceptance – Finally, Home Health Agencies came to terms with the new rule & began to aggressively implement fundamental changes in their respective businesses and hoped for the best!!!
“it is not possible that CMS would implement such a harsh rule on us AND only give us 45 days to prepare!!!”
As the new rule of Pre-Claim Review got implemented in the state of IL, we noticed a growing number of Home Health Agencies either selling their businesses or shutting down. There are reports of over 200 Medicare Certified Home Health Agencies shutting themselves down in Illinois. But why?
Agency Owners who had even a little bit of experience in the industry realized that this new rule would be a small business killer. The most commonly believed reasons for this mass shutdown are below:
Short notice of PCR Implementation
It’s a fact that Home Health Agencies only had less than 60 days to drastically change their SOP’s & bring all of their employees on the same page.
Since most small to medium sized Home Health agencies use per-diem clinicians, it was a daunting task to ensure that everyone attended clinical in-services and knew exactly what to expect as a result of the new rule. Most smaller businesses struggled with clinicians who were not compliant in submitting their patient evaluations within a decent time period.
The most difficult piece of the puzzle were certifying Physicians. Even if the Agency clinicians would complete their initial evaluations within a decent amount of time (usually 7 days), it would take an average of 15-20 days for a physician to reply with signed orders.
This delay of 20-25 days after the Start of Care would leave the agency Administrator in complete disarray. On one side, since the agency has accepted the patient, justified the need of care & already started providing services & they can’t put any services on hold for 10-15 days (until the PCR decision has been received). On the other hand, the agency has racked up quite a bit of payroll & equipment cost spent on the care for this patient, for whom they are still unsure of reimbursement from CMS.
System glitches at the PCR website
As if everything else was going smoothly, the PCR website would add to everyone’s misery. The system would randomly shut down, kick users out, declare that upload failed (after the user spent 15 minutes uploading everything) etc.
Random claim denials
This was by far the most insidious reason for the downfall of many small businesses in the Home Health Industry in Illinois.
In the beginning of Pre-Claim review implementation in the state of Illinois, CMS as well as Palmetto GBA both had made the rules very clear. Providers were made aware of the documentation & timeliness requirements. But since the kickoff, agencies & industry experts started noticing random discrepancies.
These discrepancies were brought on by the clinicians that were reviewing PCR requests on behalf of Palmetto GBA. These would range from varying documentation requirements (varying from reviewer to reviewer), to not having a pertinent reason for PCR denials. For example, two out of three PCR requests sent by an agency representative (with all of the required documentation as well as medical justification for services) would be denied on the basis of incomplete or impermissible documentation. Keep in mind that all three PCR requests were sent with ALL of the required documents needed. Agency representatives would have to re-submit the requests with the same documentation and await another set of days for the decision.
Many believe that since the number of Pre-Claim requests were such high in numbers, that the reviewers had to rely on random selection of which cases were to be affirmed and which to be denied.
Lack of Finances
All of the above-mentioned acts resulted in delaying of submission of the PCR Request, eventually resulting in the collapse of many agencies. By the time an agency administrator would get to find out that a patient is non-affirmed, their agency had already spent a significant amount of money on the care for that patient.
There were Home Health Agencies that rode this storm of uncertainty. These agencies implemented various strategies very quickly in order to sustain their survivability in the arena.
Some agencies lowered their census and paused in accepting new referrals until their staff became fully trained & compliant in the documentation timeliness. Whereas, some agencies focused more on educating the referring physicians on how important it was for their patients to comply with the documentation requirements in a timely manner.
There were a number of Home Health Agencies that would get help from their patients/caregivers in communicating with their Physicians to submit the required documentation on time.
Whats in the News
As providers in IL & FL are aware by now that Pre-Claim review has been placed on a hold (for at-least 30 days) and it doesn’t seem to be coming back anytime soon, a wave of ADR’s is to be released upon Illinois providers by CMS.
Probe & Educate II
Most providers in IL have faced ADR’s in the recent past in the “Probe & Educate” wave. This second wave of ADR’s (Additional documentation request) sent out on April 27th, 2017 is however a bit selective & will exclude the following:
One or Zero Denials in Probe I
Agencies in IL that faced the Probe & educate I back in 2015 & had either “no claim denial or just one claim denial” based on the review, will be exempted in the second wave.
Claims with affirmed PCR’s
Agencies in IL that weren’t so lucky in the first wave of Probe & Educate and faced more than one claim denial will have to be subjected to the second phase of Probe & educate audits. However, their patients with affirmed PCR decisions will be excluded from the audit.