Agencies Remain ‘Desperate’ Over Pre-Claim Despite Delayed Rollout

Having won a victory in their fight against the pre-claim review demonstration, home health providers and advocacy groups are calling for it to be suspended totally—while continuing to decry it as a historically bad program that threatens to drive a large number of agencies out of business.

Under pre-claim review, home health agencies must submit certain Medicare claims for affirmation from an auditor prior to submitting them to receive payment. The demonstration—meant to reduce improper payments and root out fraud—kicked off in Illinois last month, and was scheduled to begin in Florida on Oct. 1 before spreading to Texas, Michigan, and Massachusetts. However, following reports that the implementation has been disastrous in the Land of Lincoln, the Centers for Medicare & Medicaid Services (CMS) announced late Monday that the demonstration would not begin in Florida as planned. The agency will provide a 30-day notice before beginning pre-claim in any of the additional states.

The news brought relief to some providers with a significant presence in Florida, who spoke with Home Health Care News on the condition of anonymity. They were gathered in Chicago on Tuesday for a summit on pre-claim convened by home health software provider Homecare Homebase.


“I was sweating bullets until the moment [I learned of the delay],” one of these providers said.

Despite the reprieve in Florida and other states, CMS has not suspended pre-claim in Illinois. The program will continue there, with agencies getting extra education on topics such as how to submit pre-claim review requests and documentation requirements, CMS stated. Attendees at Tuesday’s summit denounced the decision to continue pre-claim in Illinois.

“How can you decide to delay in Florida because it’s not working, but still keep Illinois involved?” one attendee asked.


The Fight Goes On

Part of the reason behind Florida’s delay may be that CMS received a letter from the state’s two U.S. Senators—Republican Marco Rubio and Democrat Ben Nelson—speaking out against pre-claim. However, Senators Dick Durbin (D) and Mark Kirk (R) of Illinois have been silent on the issue.

The Illinois Homecare & Hospice Council (IHHC) is working to make inroads with Durbin and Kirk, and is generally pushing hard against pre-claim on all fronts, said IHHC Executive Director Sara Ratcliffe. On Tuesday, she had a call set up with the Illinois Medical Society to try to bring physicians to the fight, and she also is in the process of enlisting support from hospital groups and AARP.

Last week, Ratcliffe was in Washington, D.C., speaking with lawmakers, and she reported that some have agreed to send letters to their colleagues urging them to push back against pre-claim.

However, Ratcliffe and her colleagues rely on information they receive from providers to use as evidence in this type of advocacy, and so far only about 20 of the roughly 900 agencies in Illinois have shared their data and pre-claim experiences with IHHC, she said. She urged attendees at the summit to communicate with IHHC if they haven’t, and said that the organization is considering doing proactive outreach to solicit provider input.

IHHC also is coordinating with provider associations at the national level, such as the National Association for Home Care & Hospice (NAHC), which has called for pre-claim to be halted in Illinois. So has the Visiting Nurse Associations of America (VNAA).

“While VNAA agrees that home health agencies, physicians, patients and Medicare Administrative Contractors in Illinois should receive additional education and support, we strongly believe that immediate suspension of Pre-Claim Review in Illinois is the more prudent approach,” said CEO and President Tracey Moorhead, in a press release issued Tuesday.

‘Desperate’ Providers

Providers attending Tuesday’s meeting sounded off about their pre-claim experiences, echoing many of the complaints that have become common since the demonstration got underway.

A major refrain was that there is apparently “no rhyme or reason” as to which pre-claim submissions get affirmed versus denied. Some agencies said that after an initial rejection, they have re-submitted without making any changes to the documentation and have had the claim affirmed.

Leaders with one agency said they have experimented by submitting claims with various types and quantities of information, and can determine no pattern as to what gets affirmed and what gets denied, causing them to conclude: “We have discovered there’s no such thing as best practices.”

Some of the harshest criticisms were regarding how pre-claim has affected home health patients themselves. Medicare beneficiaries receive a letter from CMS informing them when their claim has not been affirmed, which confuses and frightens them.

“Patients are getting letters that they’re no longer covered for this service,” one attendee said. “We had a gentleman call our agency crying. He had had a heart attack, his wife passed away, he said I want you to stop the services, I can’t pay.”

Beneficiaries also have a hard time understanding what the pre-claim review is, and they believe that the letter reflects poorly on the agency providing care, others noted.

“Patients who like you suddenly think you’re a crook,” one provider said.

If Medicare beneficiaries elect to drop home health services because they are scared by these CMS letters, it likely will drive up hospital readmissions, several people observed. This reflects how misaligned the pre-claim review is with other CMS goals, such as keeping more patients in the lowest-cost care setting possible, they argued. It also will hurt providers trying to succeed in CMS initiatives such as value-based purchasing, which reward agencies for keeping customer satisfaction scores high and readmissions low.

A general consensus emerged around the notion that if pre-claim review does persist, more standardized data submission processes and pre-claim review criteria need to be established. But the clock is ticking; going through the pre-claim process and appealing non-affirmed claims slows down cash flow so much that agencies could be forced to shut their doors or stop providing Medicare-reimbursed services.

IHHC has heard anecdotal reports of agencies closing due to pre-claim, but does not have a confirmed instance, said Ratcliffe.

One summit attendee argued that pre-claim could spell the end of all but the large, publicly traded providers that can turn to the markets for capital; and leaders with those companies indeed have said that they can weather pre-claim while smaller players may not.

Overall, the situation—and providers’ mindset—might summed up in one word that was spoken by several people at Tuesday’s event: “Desperate.”

Written by Tim Mullaney

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