Fifteen minutes from Palmetto Government Benefits Administrators, the Home Health Medicare Administrative Contractor for Illinois and other states, lies the home ballpark of the Columbia Fireflies, the Single A farm team for the New York Mets. Just a quick drive down South Carolina Highway 227, any PGBA executive might learn a valuable lesson with a visit there.
He or she would find that, in spite of all the sports page headlines, former Heisman trophy quarterback Tim Tebow is not there. He has not made it as far as the lowest minor league rung yet. After signing a contract with the Mets, he was sent directly to their Instructional League team in Port St. Lucie, Florida. They wisely decided he needed months of intensive training before he, though a world-class athlete, would be ready to face even a minor league pitcher.
Were PGBA executives as wise as Mets executives, they would have done the same thing with all the new hires they brought on board with the extra money CMS gave them to manage the tsunami of paperwork expected from Medicare’s 5-state Pre-Claim Review experiment. Had these rookies been properly trained before being thrust to the front lines of document review, it is possible CMS might have avoided the fiasco that is going on in Illinois, the first state to pilot PCR.
Instead, due to what appears to be rushed, superficial training, PGBA PCR reviewers are making so many mistakes they are causing increased costs for Illinois home health providers, the unnecessary expense to Medicare of increased hospital readmissions, and extreme consternation among beneficiaries. It is this seemingly endless list of mistakes that forced CMS to postpone scheduled start dates for the same experiment in the other four states, though their announcement suggests it is Illinois HHAs that need more education. [Specific details about misinformation provided by CMS officials on submitting PCR claims by IL providers are noted in this article, along with the resulting difficulties experienced state-wide. Arguments about the PCR claims process noted by government and NAHC representatives are provided, and moves toward halting the PCR process in other states are described. The effects on patients of having healthcare at home agencies’ PCR denial rate skyrocket to 60% to 80% are discussed.]
All of these problems were avoidable yet predictable. PGBA, it will be remembered, is the MAC that blatantly misinterpreted the intent of Congress with regard to the Face-to-Face certification rule, denying thousands of claims over typos and dates placed on the wrong line instead of using the rule to expose fraud and exclude criminals from the industry’s midst. It surprises no one that Illinois is already reporting a 60% to 80% denial rate of pre-claim reviews even though their claim denial rate was nowhere near that high before PCR began.
What CMS told you
When Jeane Nitsch, Director of the CMS Division of Compliance Projects and Demonstrations, and Jennifer McMullen, member of the CMS Pre-Claim Review Demonstration for Home Health Services Team, told Open Door Forum listeners on June 14 how pre-claim would work, there was a palpable undertone to every listener’s question. It said, “Well, that’s not going to work!” They were prescient.
| Nitsch and McMullen said: |
Illinois is experiencing: |
| You will submit the same documentation you submit now with your claims. The only difference will be that you submit it earlier. |
Denials (called “non-affirmations”) are returned for missing documents that have never been required with claims, only for ADR responses. E.g. For recerts, reviewers are demanding to see every plan of care from every previous episode and the F2F document from the first episode, which they are not authorized to do. |
| Your response will be issued within 10 days. |
11-20 days is as common as 10 days. |
| Your response will be sent to you in the same format you sent the PCR documents. I.e. electronic submissions will receive electronic replies, fax to fax, U.S. Mail to U.S. Mail, etc. |
Response formats are random. Many submissions via PGBA’s “eServices” portal receive U.S. Mail replies. Some come by Fedex. When that happens, the result in the letter does not appear on the portal. |
| CMS will educate physicians on the need to sign your documents at the beginning of an episode. |
No physician education appears to have been done. Most agencies report they themselves are informing their referring physicians for the first time of the existence of PCR. |
| We are providing additional funding for the MACs to hire and train enough staff to manage the additional work. But we decided HHAs will not need additional payments as the workload is expected to be minimal. |
Most Illinois providers report the need to dedicate two or more FTEs to the unexpectedly massive additional paperwork processing burden. |
| This will be an educational tool to teach agencies how to submit the correct documentation, making claim denials less likely. |
Non-affirmations bear no indication what is wrong and how to fix it. They are marked “non-affirmed” or “education,” nothing more, no explanation as to why it was denied, on which document the error can be found, and what sort of error it is. |
(For more Illinois experiences, see “Illinois Providers Frustrated, Angry, But Not Powerless” elsewhere in this week’s issue.)
With regard to that last Illinois experience, we were told by Micah Roderick, Public Affairs Director for the Illinois Homecare and Hospice Council, that members tell him it is like getting back a multiple choice high school quiz with a D- grade but none of the wrong answers redlined. “How do you learn from that?” he asks, rhetorically. “How do you learn from your mistakes and submit a corrected PCR the next time if you don’t know what your mistakes are?”
He answered his own question. “Some of our members have sent in the same exact documents with no changes after getting a non-affirmation. The second time, it gets affirmed. Go figure.”
Although this last experience is all the proof one needs to realize that inadequate PGBA reviewer training is the culprit, there is plenty more proof. In a September 22 conference call, NAHC’s Bill Dombi summarized a book-length list of stories his office has received from Illinois providers of unfounded non-affirmations. He concludes, “Many of these non-affirmations are based on reasons that simply do not exist in the rules, not just in home health but anywhere in Medicare.”
Deflecting blame
In its September 19 announcement that Illinois would continue in the PCR experiment but the other four states would not begin as scheduled, CMS made it clear how it is going to spin the problems that led to the decision to delay. Most Illinois providers read the statement, “Based on early information from Illinois, CMS believes additional education efforts will be helpful before expansion of the demonstration to other states” as squarely placing the blame on HHA incompetence. Nowhere has a CMS staffer made mention of errors on the part of PGBA, not in writing nor in conversations with NAHC.
In fact, IHHC has already found the need to defend its members with its Senators. Staffers for Democrat Dick Durbin and Republican Mark Kirk have been rebuffing provider and association pleas to help them convince CMS to turn off PCR in Illinois by quoting from a letter they received from CMS. In the letter, CMS makes it clear that provider incompetence is the problem and that they have done everything properly to make sure PCR works efficiently. Most often, phone calls to Senators are not returned; instead terse letters are sent repeating the CMS point of view.
That door finally cracked just a little this week when one agency owner somehow got past Senator Durbin’s defensive line. Susan Platt, of Spoon River Home Health Services in Farmington, outside Peoria, told us that the Durbin staffer in charge of healthcare affairs did finally call her back, after she had left many messages. He appeared to accept the possibility that the CMS slant might not be entirely accurate. IHHC has promised to help Ms. Platt pry that crack open a little more.
Keeping the lid on for the other four
IHHC and NAHC are urging every HHA in the five pilot states to contact their Representatives and Senators as soon as possible, telling the Illinois/PGBA story. Until CMS and its contractors figure out how to teach the rules accurately to their reviewers, they say, Texas, Florida, Michigan and Massachusetts will certainly experience the same problems Illinois is reporting.
Appealing to Florida’s Congresspersons and Senators does seem to have been what put pressure on CMS to postpone PCR, Dombi opined during his 9/22 conference call. Marco Rubio and, of course, all Representatives are up for re-election. That makes politicians unusually receptive to responding to constituent demands.
“This is creating a crisis at a bad time for elected officials,” Dombi figures the bureaucrats are thinking. “CMS does not want to find itself in middle of an election fight because of problems caused in five states, especially Florida, which is so important in the electoral college vote count for the Presidential race.”
What about the patients?
Illinois Senator Kirk’s office said it is only interested in receiving stories about Medicare beneficiaries not getting the care they need. Of course, that has not happened yet but IHHC and NAHC are certain it will. With a 60% to 80% PCR denial rate, they say, HHAs are soon going to have trouble meeting payroll. If they resort to layoffs, a possibility, they will start turning away referrals. In rural areas, with no in-home services available, Medicare beneficiaries will have to move to Skilled Nursing Facilities or hospitals. The end result will be skyrocketing Medicare costs.
Before that happens, patients are already distressed. One of the little known provisions of the PCR experiment is that a letter is automatically generated to the patient with every non-affirmation. Letters inform the patient that their home health agency has received a decision of non-compliance with billing regulations. Agencies have been receiving alarmed phone calls from frantic elderly patients, asking if they are being cared for by bad people.
©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
