Arriving at a complete understanding of the complex Illinois experience under the first Pre-Claim Review pilot and interpreting it for our readers is too large of a task at this early date. Instead, we offer nearly all of the comments we have heard — from Illinois providers, the Illinois Homecare and Hospice Council, and NAHC — without comment. Let readers come to their own conclusions. [Rowan provides a cogent review of responses that he received from the Palmetto Government Benefits Administrators (PGBA), multiple healthcare at home providers who took part and submitted claims in the state of Illinois pilot program for submitting pre-claim reviews (PCRs), among other commentators. Details about specific problems with submissions –and also means for circumventing problems with submissions– are noted.]
PGBA came to Illinois in July, put on four trainings across the state. Then they moved on to Florida and Texas. Since then they have posted some webinars online.
Non-affirmation rate for Illinois Pre-Claim Reviews is as high as 80% in most of the state. HHAs attached to large hospital systems report a 50% denial rate. Most approvals, however, are still marked “provisional.” Neither CMS or PGBA has explained what that means.
Reviewers at PGBA provide no explanation for denials, as CMS has instructed them to do. They may say “no evidence of medical necessity” but offer no further education or detail, making it impossible for the agency to know what changes to make when they resubmit for a second review.
Many HHAs are astonished and puzzled to report that they have occasionally resubmitted after a denial, making no changes, and the second time it is affirmed. Apparently, it depends on which reviewer you get, even though the decisions are supposed to be rule-based, not subjective.
Resubmissions are supposed to require only the corrected documents. CMS says it is working on a systems upgrade but at present reviewers have no way to associate a second submission to the original, denied request. No matter how many pages are submitted, reviewers see them as one long, consolidated document. They either cannot or will not search for earlier iterations from the same episode. According to what Bill Dombi has been told, they are not even aware they are looking at a second submission or that there was a first one.
Because of this problem, PGBA reviewers are unable to comply with the CMS rule that they must not issue a second non-affirmation for a different reason that was not found to be deficient in the first submission. However, as they are unaware they are looking at a resubmission, they frequently look into the documents that were deemed acceptable the first time and find flaws in them, not knowing they are violating the rule.
Patients receive a letter every time there is a pre-claim non-affirmation. Many of them become distressed and call their HHA in a panic, asking what it means.
Originally scheduled to begin on August 1, a Monday, CMS changed its mind at the last minute. PCR documents can only be submitted for episodes beginning on or after August 3. Nevertheless, many HHAs report that they have received PCR non-affirmations for episodes that did in fact begin on or after August 3, with the denial reason, “PCR cannot be submitted for episodes that began prior to August 3.”
When PGBA specifies information needed, they often ask the same question in three different places. HHAs have learned reviewers will not search through the documents to find the answer so they have learned to submit the same exact document three times. Otherwise the reviewer will claim the question was not answered.
Contrary to established norms, PGBA requires separate documentation for every discipline. Prior to PCR, an episode could start with physical therapy only, but if the patient has a medical change in condition, perhaps takes medications wrong and becomes seriously ill, the agency could send in a nurse. Under PCR, PGBA tells providers, you must submit a new pre-claim review when a discipline is added mid-episode.
If the PCR is for a recert, PCGA reviewers are demanding to see the Face-to-Face document from the original episode and plans of care from all episodes. In Bill Dombi’s opinion, they are not allowed to make these requests. Nevertheless, an agency cannot object without risking an automatic denial.
Emerging Solutions
On the optimistic side, some agencies have found a path or two through the chaos.
One agency produces cover sheets for physicians to sign. They include a list of all the documents the agency provided to the physician with a signature line that says something like, “I acknowledge that I have received the following documentation from ABC agency.”
Regarding the cover sheet idea, Bill Dombi said NAHC has presented such a form to CMS to look at and they have indicated it is acceptable to ask the physician to affirm the records he or she reviewed for your patient.
One agency is calling patients on the phone as soon as they know they have a non-affirmed PCR. They alert the patient that they will be getting a letter from CMS and telling them is has nothing to do with the quality of the care they will continue to receive.
IHHC has been in communication with the Illinois Medical Society, giving them information they can use to teach their member physicians about. The group is open to hearing more because it wants patients to receive the best care. These conversations will continue.
PGBA also seems to misunderstand what documents are required. Though CMS assured providers last June that PCR would pose no significant administrative burden, that providers would be asked to merely submit the same documents they submit now with final claims, Illinois providers are finding that PGBA is actually demanding all the same documents they request for an ADR. Many agencies have had to hire additional staff to handle the burden.
Physicians, tired of HHA demands for signatures and certifications early in the episode, are beginning to avoid home health altogether, sending patients back to the hospital.
CMS promised a 10-day turnaround when responding to PCR requests. One agency reports eight PCRs submitted before September 1 that had not received responses as of September 22. Many other agencies
The method of response is supposed to match the method of submission. Many agencies report that they submit electronically but receive responses by U.S. Mail or Fedex. PGBA offers no explanation for the chaos and confusion. CMS only states that all responses come back the same way they were submitted, even though they have been told this is not the way it has been happening.
PGBA is supposed to have a system that allows reviewers to match resubmission documents with documents from the original, denied submission. It does not have such a system. If it did, agencies would be able to send only the changed documents after a denial. Reviewers would be able to find the original and combine the two. Instead, resubmissions must include all documents, even the ones that needed no corrections.
Inaccurate instructions seem to arrive frequently from PGBA. One agency administrator reports, “I was told to list the names of all physicians in a practice because PCR reviewers would otherwise not know which physician in the practice is responsible for the patient. “This makes no sense,” Dombi reacted, “because Medicare’s policy is that you cannot have two different individual physicians, one the homebound certifier and another who completes the F2F document.”
In response, some smaller agencies are holding off on submitting PCRs until the dust settles, or until CMS gives up and suspends the pilot in Illinois until PGBA improves its performance. Some providers say they are holding recert PCRs but submitting them for new episodes. One larger agency said it wanted to hold off but could not. “We submitted 500 already and have 600 more being prepared.”
Searching for consistency
With all these errors and rules violations occurring every day in Illinois, both the state association and NAHC are calling for the pilot to be aborted, reasoning that if the system is not ready for the other four states it is not ready for Illinois either.
IHHC and NAHC acknowledge that the purpose of PCR is to get fraud and abuse under control. They question, however, the effectiveness of subjecting every provider to the same cure. IHHC’s Public Affairs Director Micah Roderick knows well that the association is aware of the fraud and abuse problem and supports all efforts to root it out.
“It helps no one,” he told us. “It gives the entire industry a black eye. But there have to be ways to tackle the problem without punishing everyone.” Besides, he continued, the bad guys will figure a way around it and only honest agencies will be harmed. He fears hospital readmission rates will skyrocket when agencies start closing or turning patients away because PCR is not being executed correctly.
Susan Platt, co-owner with her husband of Spoon River Home Health in Farmington, Illinois, reminded us that the MACs and ZPICs seem to have no trouble identifying abusive HHAs when they issue ADRs or place agencies on focused medical review. “They know who the bad guys are,” she moans, “why can’t they just go after them instead of making the rest of us jump through all these expensive hoops?” She added that she had asked that question of one CMS official who explained that “it takes six years to build a case against a fraudulent agency.”
NAHC’s Dombi agrees. “They have enough information now to figure out what is going wrong and what they have to do to fix it. They are not going to learn anything more by continuing in Illinois.”
©2016 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com
