Category / Pre-Claim Review

by Julianne Haydel

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.

 

by Julianne Haydel

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).