Here We Go Again

A notification of the intent to re-implement the Pre-Claim Review process is being published today in the Federal Register.  The purpose, as stated in the notice, is to develop and improve methods to investigate and prosecute fraud in the home healthcare services.  In other words, Medicare wants you to send them evidence before you are even suspected of a crime. At its onset, agencies in Illinois, Ohio, Florida, North Carolina and Texas with the option to expand.

If there was even a chance that this burdensome, intrusive and expensive process would serve its stated process, my objections might not be so strong (but maybe they would).  Assuming that this process involves collecting the same information as the 2016/2017 demonstration, it is not likely identify or help in the prosecution of fraud. For those of you unfamiliar with the process, agencies had to gather and submit eligibility information for patients and submit it prior to billing the final claim.  (Palmetto GBA’s Guide to PCR submission) What’s even more amazing is that the United States Congress agrees with me.   

Here’s what they wrote in the Final Rule for the 2015 PPS update:

Each year, the CMS’ Office of Financial Management (OFM), under the Comprehensive Error Rate Testing (CERT) program, calculates the Medicare Fee-for-Service (FFS) improper payment rate. For the FY 2013 report period (reflecting claims processed between July 2011 and June 2012), the national Medicare FFS improper payment rate was calculated to be 10.1 percent.  For that same report period, the improper payment rate for home health services was 17.3 percent, representing a projected improper payment amount of approximately $3 billion.  The improper payments identified by the CERT program represent instances in which a health care provider fails to comply with the Medicare coverage and billing requirements and are not necessarily a result of fraudulent activity.

Worse than being ineffective, the proposed PCR project does not state goals of prevention of fraud, improvement of patient outcomes, or identification of opportunities for innovative approaches to home healthcare.   The process focuses on Face-to-Face information, documentation of homebound status, signatures and dates, and care plans. Nothing written here is meant to dismiss the importance of these statutory requirements but agencies who are fraudulently bent are coached by the CMS in how to get paid whether or not visits are being made or if the ordered care is given. Numerous checklists and examples could serve as a Fraud 101 primer.    It befuddles me that an undated signature may result in a denial or delay in payment but Medicare doesn’t understand that a fraudulent agency may document homebound status perfectly even when the details are contrary to reality.

But you do have a choice.  You can opt out of the PCR process.  It’s a condescending choice like when a toddler is told he can eat his vegetables or be sent to bed early with no dessert. Most kids will hold their nose and get the Broccoli down.  

Similarly, Medicare is giving agencies a choice to participate in PCR or suffer a 25 percent reduction in payment IF they are paid after a mandatory request for additional records (ADR).  So agencies will hold their nose and participate in PCR.

Agencies can also opt for a post payment review. In this scenario, you would submit information after being paid which means any errors found occurred prior to billing.  Undated signature? Denied. Then you will have an overpayment which will be recouped. There are few things worse than having money you already earned taken back. But agencies have a choice.

Agencies will be removed from PCR after they reach an unannounced target goal. If the purpose of PCR is accurately stated, how could the goal be less than 100 percent?  If a 90 percent target is set, that means that 10 percent of claims meet the categories of fraud, abuse or waste.  

What has never happened to the best of my knowledge is anyone being notified by the person reviewing a patient in the pre-claim review process of errors that might cost Medicare money. Just once I would like to see advice to an agency to include therapy because even though it was received in a prior admission, it’s worth another shot because the patient is having pain difficult to manage without opiates increasing the risk of falls and subsequent injury.  

Luckily, you don’t have to sit back and wait for the curtain to fall.  You have been invited to comment on the PCR process. Before you do, take a look at the document which was to have been included in today’s Federal Register.  As of now, it does not appear to be there.

Note that there are multiple ways to submit your comments.  Use them all. Tell your co-workers, bosses, employees and mother to read the memo and draw their own conclusions.  There is an ethical dilemma if you tell them how to feel about a political matter but providing a stamp won’t draw the attention of anyone.

Also note the title of the gentleman who signed the memo; Director, Paperwork Reduction Staff.  I couldn’t make that up if I tried.

The Coders will prepare comments for submission and share them with you. Please feel free to share your comments for or against the reimplementation of the Pre-Claims Review Demonstration.  And remember, you have options.

 

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2 Comments

  1. We just completed our probe and educate audit. Our auditor stated that we scored “phenomenally” with just 1.1% error rate. Why would you continue to harass agencies
    with that kind of record instead of using that probe to go after the ones with high error rates.
    This auditor told us we did better than anyone she had reviewed. This action makes no sense.
    Doing the PCR on agencies with poor records would save the government millions of dollars.
    Addtionally, the PCR process is going to cost our relatively small agency so much that we will not be able to survive. We are barely getting by as it is. If CMS used current records in their analysis instead of those that are 5 years old, they would see how much less we are making than we did in years past thanks to all the cuts to reimbursement and the increase in paperwork. When PPS started years ago a nursing assessment was two pages long. Now due to the convoluted process the nursing assessment (Oasis) is 34 pages long, just so they can include questions that ultimately cost the agency money if not answered the way CMS requires it to be answered in order to be paid for the services. Unethical agencies will instruct their employees to answer the questions so that they will make more money. This punishes the agencies that are ethical and demand ethical behavior from their employees.

    Reply

    1. Shirley, there is nothing worse than a denial for care provided to an eligible patient. And in our experience, errors are more likely to be made when there aren’t enough people to do the job and people are rushed.

      You are correct in that resources would be better used if they were spent on agencies with a high probability of fraud. In every community we work, our clients know who the fraudulent agencies are. Why isn’t Medicare able to find them?

      Maybe the truth is that there is less resistance when a little money is taken from a lot of agencies who can’t afford the lawyers, consultants and other resources required to fight a huge judgment. And if they somehow manage, the money is gone before Medicare gets any.

      Thanks for commenting and I hope you’ll take the time to send your comments to CMS.

      Reply

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