Medicare’s Pre-Claim Review Demonstration Project

Imagine if every one of your Face-to-Face documents and plans of care were scrutinized prior to payment.  Would 90 percent of them be found compliant with existent rules?  If a non-clinical person determined that your documentation did not meet Medicare coverage guidelines, would you take their word over your nurses’?  How would you feel about submitting a perfectly valid claim for eligible services and being paid 25% less than your peers?

Agencies in Illinois do not have to use their imagination.  It is already happening through the Pre-Claim Review process.  This process involves submitting plans of care, face to face documents, physician and hospital notes and sometimes more to Palmetto prior to dropping a claim for ‘affirmation’.  Once affirmed, a secret code is given to the agency which is placed on the claim. Without the code, final claims are reduced by 25 percent.

And while Medicare is reporting a 90 percent ‘affirmation’ rate, it does not report that there were over 80,000 RAPs submitted compared to 23,000 final claims.  Agencies are apparently reluctant to submit their pre-claim review documentation.

Because a RaP will be taken back after 120 days if not answered by a final claim, I expect that many agencies are going to drop an enormous number of claims in the coming weeks which means the number of pre-claim reviews will far exceed that ever imagined by Palmetto, GBA.  Maybe Palmetto really can process an additional 60k reviews without any interruption in services to the rest of us.  Maybe; but I doubt it.

In April, Florida will come on board.  Texas, Michigan and Massachusetts will follow at undetermined dates.

Agencies in states other than Illinois might not be impressed with all this stuff and nothing.  They are busy with the changes to the OASIS data set, the impending Conditions of Participation and perhaps their own audits or surveys.  Hopefully they will take pause and consider the magnitude of this demonstration project to understand the egregious nature of this intrusive and burdensome little project taken on by Medicare.

The new conditions of participation expected in July of this year explain that the prior Conditions focused on identifying agencies with poor performance.  The updated Conditions of Participation take a much-needed step away from this punitive approach.  As written in the new regulations:

Ensuring quality through the enforcement of prescriptive health and safety standards, rather than improving the quality of care for all patients, has resulted in expending much of our resources on dealing with marginal providers, rather than on stimulating broad-based improvements in the quality of care delivered to all patients.  

There is nothing about the Pre-Claim Review process that stimulates broad-based improvements in healthcare.   How could the Pre-Claim Review Project be so far removed from the intent of the home health Conditions of Participation?

Consider that the demonstration project is resulting in difficulty meeting the educational demands in Illinois and that resources have already been relocated from Florida to Illinois.  Do agencies in other states have the same access to education as the agencies under pre-pay review?

According to the Medicare Pre-Claim Review Q & A:

The demonstration establishes a pre-claim review process for home health services to assist in developing improved procedures for the investigation and prosecution of Medicare fraud occurring among Home Health Agencies providing services to Medicare beneficiaries.

Nobody can deny that a small number of agencies operate without any regard to Medicare rules and only a passing acquaintance with ethics.  This inconvenient acknowledgment of fraud amongst the ranks does not justify excessive scrutiny on 100 percent of providers.  Somehow it does not seem fair to involve home care agencies in a demonstration project designed to enhance their prosecution.

And yet, agencies who fail to submit documentation for a Pre-Claim Review are put on a 100 percent review – a level of scrutiny previously reserved for agencies operating far outside of Medicare rules for an extended period.

The documentation required for a pre-claim review is reviewed for clerical errors and dare I say, elements that cannot be established with limited documentation by reviewers who are not nurses.  The reason for denial given most often per Palmetto GBA is lack of medical necessity.  We see care plans daily that are very poorly crafted supported by excellent nursing and therapy notes.  Conversely, we see plans of care worthy of a Pulitzer prize supported by 9 visit notes at weekly intervals documenting that a skilled nurse taught meds – presumably meds ordered for the patient but who knows?  Nobody asked us if it was possible to determine Medical Necessity without a complete review of the chart.

In the same vein, we see homebound status documented on visit notes that is contradictory to plans of care.  In one recent chart, we found that a patient was shopping weekly.  On another, a therapist documented the patient was driving.  Sufficient documentation on a plan of care that a patient meets the homebound criteria does not make it so.

But, the reviewers are also quick to note when a signature is not dated or the date of encounter is omitted from the Face-to-Face encounter document.  I agree that dates are an important step towards compliance but lack of a date is often nothing more than an oversight; not a tell-tale sign of fraud on behalf of the agency, especially since it is the physician who responsible for the dates.  If this keeps up, the federal prisons will be filled with healthcare providers who forgot to date a couple of documents.

The burden to the agency is extensive.  On a recent CMS conference call, many agencies reported that the PCR process was costing them $25,000.00 per month.  Another agency stated it was taking them about an hour per claim.  Even if these estimates are overstated, they are still far above Medicare’s estimation that it would take minimal time and expense to get the pre-claim reviews submitted.

If Tom Price is confirmed as the new secretary of HHS, there may be some relief but the Georgia representative will oversee 13 different agencies including CMS, the CDC, the FDA, National Institutes of Health and more.  While he has been outspoken against the Pre-Claim Review Process as a senator it is hard to imagine that the Pre-Claim Review process will find its way to the top of his priority list upon confirmation.

So, who benefits from this circus?  Is Palmetto being honest when they say the project is going well?  Are our patients happier and healthier because of frantic efforts to assemble and transmit paperwork?  Could the resources being consumed by The Pre-Claim Review project be put to better use?  What can you do?

I can only provide an answer for the last question.  The first thing you should do is to contact your elected officials in Washington.  After that, get your care plans and Face-to-Face documents in order because there is now an abundance of reviewers at Palmetto who are fluent at reviewing (and finding cause to deny) them.  If you are in Illinois and have claims that you believe are non-affirmed due to incompetent reviewers at Palmetto, contact NAHC.  Under no circumstances do we recommend ignoring the Pre-Claim Review Process because your state is not in the demonstration project.

Many Thanks to Tim Rowan, founder of the Home Care Technology Report. who has extensively and  investigated the Pre-Claim Review process and its effect on providers.  His articles are linked within the content of this post and you can find additional information on his website.

And of course we want your comments and questions.  You can leave a comment here or email us with questions.  We particularly want to hear from Illinois agencies (after you contact your elected officials).


  1. *waves* Hi! I’m a home health nurse in Illinois. PCR is…brutal. Absolutely brutal. It has forced us all to become better at documentation, I’ll give them that. Hasn’t particularly helped me to be a better nurse, though. If anything, I’m slipping (although thank goodness it hasn’t impacted patient care – but it’s amazing I haven’t gotten any driving tickets yet). I’m exhausted. I’m so far behind on my regular visit charting, I’m amazed I haven’t been fired. My SOC OASISes are taking me 2+ hours to complete again. I feel like a new hire. So many companies in our area just went out of business in August rather than deal with PCR (including some big ones connected with hospitals!) that we can’t keep up with all the referrals. Yay for business, but ugh…

    My biggest tip for states where this is coming: get your nurses’ documentation in line now. Develop a really solid homebound status justification that includes all the buzzwords Medicare uses that your nurses can plug risk factors, symptoms, and diagnoses in. Add a section in the OASIS where you expressly justify the need for each discipline. You’ve got to spoon feed this stuff to the adjudicators. They won’t go looking for it all over the OASIS, and they won’t assume anything. (We put this together on the “Initial Summary of Patient History” section of the OASIS-C2.) And hire some more nurses, at least part time, because you’re going to need them to be able to take the patients that other companies are leaving in the lurch.

    (Also, and I know you know this, but your blog made it a little unclear: driving is not an automatic disqualifier for homebound status. If your patient can drive, but needs human assistance and an assistive device to get into and out of the car and walk on uneven ground, so she needs to arrange for someone to go with her to the doctor every time she goes, and she leaves the house infrequently and for a short period of time because her medical condition makes it just so hard…totally legitly homebound. Not theoretically; that was a patient I got affirmation for after PCR started.)


    1. I am exhausted reading your account! Thanks for sharing. Florida is next – they have almost 50 percent more agencies than Illinois!

      At some point, we need to free up resources for patient care. I believe you when you say that your skills are intact but have you gotten any better at caring for patients? Does you agency have the funds to send you to say, a diabetes seminar or wound care workshop?

      Hang in there. Tom Price’s confirmation was delayed but hopefully he or someone else who will hear us and take action will be next.

      Go get some rest!


      1. I’ve certainly learned a lot and become a better nurse over time…but honestly, not really since PCR. I’ve been doing, and learning, a lot of wound care, and I’d really like to get certified, but there are just not enough hours in the day. I had planned on doing it this year, not realizing just how much less time I’d have. This is a serious, unanticipated, and unintended side effect of the PCR process. When you tie up your nurses’ time with additional documentation burdens, they have less time to take the classes they need to become better nurses.

  2. ….AND….I just got my first parking ticket at work in over a year. Darn it. I jinxed myself. At least it wasn’t a moving violation! But I was literally so tired I read the time on the sign wrong and parked where I shouldn’t have after 4:00. Think Medicare will reimburse me for it? 😉


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