Lawmakers Urge CMS to Halt Pre-Claim in Illinois

In the aftermath of a pause on the the pre-claim review demonstration (PCRD) elsewhere, lawmakers in Illinois – where the demonstration has been ongoing since August 3 – have asked for a delay in the Prairie State, as well.

In a letter to Andy Slavitt, acting administrator at the Centers for Medicare & Medicaid Services (CMS), Rep. Tammy Duckworth (D-IL), U.S. Sens. Dick Durbin (D-IL) and Mark Kirk (R-IL) and the entire Illinois Delegation asked PCRD to be delayed in Illinois. Home health agencies have reported high non-confirmation rates for their pre-claim submissions, burdensome and time-consuming administrative demands and inconsistent results since the demonstration got underway. Recently, federal legislators also took a stand by introducing a bill in Congress that would put a one-year moratorium on PCRD.

“Seven weeks into the PCRD, the experience of this pilot in Illinois has resulted in severe burdens on patient access to care and provider capacity,” the letter reads. “We urge CMS to delay further implementation of the PCRD in Illinois, which CMS has already announced they will do for other states.”

The lawmakers noted that while the demonstration is aimed at preventing fraud, the current model is still too burdensome and puts patients in jeopardy. The letter also cited the 60% to 80% rejection rates being reported by home health care agencies in the state.

“We remain concerned that implementing the PCRD as presently structured, and without sufficient education and training, jeopardizes the delivery of care to needy beneficiaries,” the letter says. “Illinois’ experience under the PCRD has been alarmingly burdensome for home health providers, which is harming patient access to care.”

Lack of education has been a key factor in the rollout in Illinois, where home health agencies have reported that getting a physician’s signature earlier in the care process for pre-claim obligations has been challenging. During its delay for Florida, Texas, Massachusetts and Michigan, CMS has since stated that it will double down on education efforts for providers to understand their requirements.

Prior to sending the letter, Illinois lawmakers said they were collecting more information on the impact the demonstration was having on home health agencies and patients. Lawmakers sent a letter in April, prior to implementation, over their concerns the model could have negative effects.

“Efforts to improve Medicare program integrity are critical to the fiscal future of our country,” Sen. Kirk said in a statement. “These reforms must happen in a way that ensures accurate information to patients while not jeopardizing their care.”

Written by Amy Baxter