With No Delay in Sight, Florida Agencies Brace for Pre-Claim

Despite major pushback from the home health care industry, the controversial Pre-Claim Review Demonstration (PCRD) is set to begin in Florida on April 1. Agencies in the Sunshine State have prepared for the three-year demonstration from the Centers for Medicare & Medicaid Services (CMS) while simultaneously putting up a fight for a delay or moratorium.

In fact, Florida home health companies have been on the front lines of efforts to stop PCRD from expanding by linking up with industry associations and legislators. U.S. Senators Marco Rubio (R-FL) and Bill Nelson (D-FL) have repeatedly spoken up against the demonstration, noting that the bumpy rollout in Illinois is cause for concern.

Elite Home Health, a home health agency based in Jacksonville, Florida, was able to meet with the office staff of Nelson on the issue, and called the Senator’s staff “very receptive” to assisting the agency and siding against PCRD. Elite also met with office staff of Congressman John Rutherford (R-FL 4th District) to discuss the issue.

However, even with lawmakers on the side of home health agencies in affected states, Elite’s President, Brandon Groover, is not optimistic that federal committees and agencies are as sympathetic. The results from Illinois have become controversial in discussions between providers and CMS.

“The House [Energy and] Commerce Committee, which oversees CMS, is under the impression that Pre-Claim is not burdensome, as CMS is presenting a rosy picture of high affirmation,” he told Home Health Care News. “I argued to the congressional staff that the affirmation rate could be deceptive, as CMS has included both partial and full affirmation.”

The affirmation rates in Illinois published by CMS have indeed come under fire for the fact that the rates include partial affirmation reviews. For partial affirmations, agencies will typically submit the pre-claim again.

CMS reported that Illinois affirmation rates reached nearly 92% as of mid-January. CMS has not provided an update since then. Meanwhile, Seema Verma, CEO and founder of a health care consultancy firm, has been confirmed to lead CMS.

Rooting Out the Bad Guys 

While Florida agencies voice their concerns, they are also taking notes from Illinois providers that have dealt with the demonstration since August 2016.

One Illinois provider with a 100% affirmation rate supports the demonstration’s intention to root out fraudsters. Chicago-based Simply Home Health has found success after taking a backseat when the program began in Illinois. Instead of starting right away by submitting pre-claims once the demonstration began in August last year, Simply Home Health didn’t start the process until September.

After investing in another staff member, restructuring its claims process and taking a hit to cash flow as a result of the demonstration, Simply Home Health’s CEO and Founder Bob Kunio is hopeful PCRD will at least improve the reputation of the home health industry by identifying the bad guys and putting them out of business.

“We have put in so much time and effort and money getting good at this that I’m hoping we benefit by having fewer dishonest competitors,” Kunio told HHCN. “The whole purpose is to make it difficult for the cheaters to get paid.”

However, a broad stroke to combat fraud, such as this program, causes significant burdens on do-gooders, industry groups say. Kunio also agrees that the program is disruptive to business, and advocates for a compromise of lifting the demonstration after a period of time, such as six months. Agencies that fail to start PCRD in that time could be a red flag for fraud, he says.

PCRD specifically targets the five states—Illinois, Florida, Texas, Massachusetts and Michigan—with the highest rates of improper home health payments. Florida sees itself as a target for regulations.

“From aggressive audits to reimbursement-related programs, Value-Based Purchasing, and now with the Pre-Claim Review Demonstration looming large on the horizon, the level of scrutiny on home care is unparalleled, and no other state has had to content with it as much as Florida,” Anthony Clarizio, president of the Home Care Association of Florida (HCAF), said in a statement at the beginning of March.

Groover disagrees that PCRD could achieve its aims to reduce fraudulent players, and believes other requirements are to blame for home health’s bad reputation for improper payments, not all of which are fraudulent.

“There is a false notion that PCR is truly needed,” he told HHCN. “In fact, the erroneous face-to-face requirement is the cause of the high improper payment rate.”

Despite repeated GOP promises to roll back regulations, Republicans at the helm of new positions under the Trump administration, including Health and Human Services Secretary Tom Price, have yet to stop PCRD.

“In a nutshell, I am not so sure that PCR will be beat this time,” Groover said.

Written by Amy Baxter

Photo Credit: “Welcome to Florida,” by Paul Hamilton, CC BY 2.0