Senators Push for Pre-Claim Delay After ‘Complete Mess’ in Illinois

Two U.S. Senators have called for a controversial home health pre-claim review demonstration program to be delayed in Florida, and they reiterated concerns over how pre-claim threatens providers and patients. And their concerns appear well-founded, considering reports from providers in Illinois, where pre-claim already has been implemented.

“We remain concerned this demonstration may restrict beneficiary access to timely services, divert clinical resources to paperwork management, and incur high administrative costs,” wrote Florida Sens. Bill Nelson (D) and Marco Rubio (R) in a letter to Andy Slavitt, Acting Administrator of the Centers for Medicare & Medicaid Services (CMS). “We urge CMS to delay expansion of PCRD into Florida and the other states until CMS, stakeholders, and Congress have the opportunity to evaluate and understand the impact of the demonstration in Illinois.”

Since its implementation at the beginning of August, the impacts of pre-claim appear to be highly negative in Illinois. The National Association for Home Care & Hospice (NAHC) has received reports from members that the demonstration is rife with problems—which providers also have told Home Health Care News.


‘Worst Regulation’

NAHC and providers are not mincing words when it comes to pre-claim in Illinois.

“It is a complete mess,” stated Bill Dombi, NAHC’s vice president for law, on the organization’s website. “That is the result that we all predicted given the magnitude of the undertaking that increased the MAC’s claim review workload 40-50 times of its normal volume.”


In particular, there have been “endless reports” that the Medicare Administrative Contractors (MACs) doing the pre-claim reviews are losing electronically submitted documents—something that providers also have told Home Health Care News.

Every single claim sent for pre-claim review so far has been denied by Palmetto, the MAC involved, one agency president told HHCN on condition of anonymity.

“They say we didn’t submit the face-to-face, and when we get on a conference call to review, they have the docs right there in front of them on their computer that they’ve received electronically,” the president said.

Already pre-claim is taking a toll on the agency, which may have to hire five to six nurses just to push the necessary paper to be in compliance, according to the president. Each initial submission takes at least an hour to prepare, he estimated; that number also is what NAHC has heard.

“This is the worst regulation I have seen in the PPS [prospective payment system] era,” he said. “And it appears that CMS does not care.”

In addition to rejections based on supposedly missing documentation, MACs are issuing many rejections on the basis that the beneficiary is not homebound or the care is not necessary, according to NAHC. This is having a “chilling effect” in Illinois, as providers indicate that they may not start care until getting a green light on pre-claim.

Among other complaints, NAHC has heard of one hospital-based home health agency closing its doors rather than deal with pre-claim, and another agency has said that service is being delayed four to seven days due to the demonstration.

Furthermore, MACs are not being clear in their rejection notices, leaving agencies unsure how to correct their claims, according to NAHC.

“It can be expected that access to care problems will escalate in the very short term unless CMS and the MAC reverse course quickly,” the provider association stated.

Fight Heats Up

NAHC has outlined six steps to address the pre-claim debacle, with heightened Congressional advocacy at the top of the list. NAHC says it worked “for months” on the letter sent by Sens. Nelson and Rubio.

Beyond calling for a delay to the Oct. 1 start date in Florida, the Senators argued that there are more effective ways of improving program integrity around Medicare home health documentation and payments. They also advocated for a “scaled-down” version of the program should it move forward in the Sunshine State.

“For example, home health providers in our state have suggested a random selection of a small percentage of Request for Anticipated Payment submissions for pre-claim review,” they wrote. “This would require all home health agencies to be ready to comply with the PCRD, alleviate the workload on MACs and providers, and provide CMS with the same information it currently seeks through implementation of the PCRD.”

CMS really should be focused on issues around face-to-face, the Illinois agency president told HHCN. A surge in improper Medicare home health payments over the past two years is one reason CMS undertook pre-claim review; however, that is also the timeline during which the face-to-face rule became a fiasco, leading to many payments being deemed improper, he said.

The face-to-face requirement initially called for the certifying physician to include a “narrative” about why the beneficiary required home health care, but that requirement later was dropped in the face of a NAHC lawsuit.

Other steps NAHC is taking to fight pre-claim include: enlisting patient advocacy groups for support; developing a tool to capture data showing the impact of pre-claim in real time; continual communication with member agencies; continuing ongoing communication with CMS; and potentially developing a lawsuit if harm continues.

Written by Tim Mullaney

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