Pre-Claim Tests Home Health, Physician Relationships

As Illinois home health agencies have grappled with numerous challenges imposed by the Medicare Pre-Claim Review (PCR) demonstration, making sure home health can work hand-in-hand with physicians has emerged as an acutely important issue.

Under the PCR demonstration, agencies must submit claim documentation to a Medicare administrative contractor (MAC) for audit; affirmed claims may be submitted for payment, while non-affirmed claims must be resubmitted. The requirement of having a physician signature on the home health plan of care was an early concern voiced by agencies, after the Centers for Medicare & Medicaid Services (CMS) announced in June that the pre-claim review would be implemented.

The program rollout has been blasted as a fiasco in Illinois, and CMS delayed a planned expansion to additional states after pressure from Congressional lawmakers. However, pre-claim remains in effect in Illinois, and agencies there continue to say that a major complicating factor is communicating with physicians about the new requirements and getting timely documentation that fits auditor expectations.


It appeared early on that CMS was not doing a thorough job of educating physicians about the pre-claim review, Cheryl Meyer, director of clinical excellence at Advocate Health, said Tuesday at the Home-Based Care: Financial Leadership Forum in Chicago. The event was jointly organized by the Visiting Nurse Associations of America (VNAA) and the Alliance for Home Health Quality and Innovation (AHHQI).

Physician associations began calling Advocate during the summer asking what the pre-claim review entailed, suggesting that they were not getting that information from CMS, Meyer said. Based in the Chicago area, Advocate is the largest health system in Illinois. Advocate at Home has about 1,100 Medicare episodes monthly.

Recognizing that pre-claim would indeed increase the importance of the physician documentation, Advocate has taken certain steps. Its chief medical officer sent a letter to Advocate physicians explaining pre-claim requirements, and why it is important for physicians to take the time and effort to meet the needs of the program—including that keeping transitions to home running smoothly is important to initiatives related to population health.


Advocate also has stopped accepting home health referrals until all the documentation is furnished up front, Meyer said. This is a change from the prior approach, which generally was to take accept the patient and then chase the paperwork.

If a patient’s care is delayed due to the lack of documentation, that is entered into a patient safety database, she said. Collecting data about the impacts of pre-claim on access to care is one important step that providers should be taking, so that CMS and lawmakers can have hard numbers showing the negative impacts of the program.

“We’ll have a story to tell,” Meyer said, of having that kind of data.

It was a point strongly echoed by Joy Cameron, VNAA vice president of policy and innovation. Cameron also said one of her “key concerns” is about the need for physician involvement in pre-claim, and how difficult it can be to communicate the program requirements to them. Adding to this issue is that MAC auditors seemingly are looking for very specific language, perhaps because they need further education and training themselves.

“I don’t think they’re doing this purposefully,” Cameron said of physicians not hitting all the necessary marks related to documentation. “It’s extremely confusing to have a home health agency say, ‘When you’re describing homebound status, can you make sure to use the following phrasing, because this is what our MAC really likes.’ I think physicians might have their hackles raised a little bit, because they say, ‘I said they’re homebound.’ Yes, but the MAC is looking for specific language.”

Changing Systems—and the Culture

A more long-term effort at Advocate involves working with the hospital to put in tools and processes with the goal of getting more consistently high-quality documentation for home health and other post-acute providers, Meyer said.

This is the sort of project that would have made sense to embark on even prior to pre-claim, given that health care reforms generally are increasing the importance of smooth transitions and sending patients to most appropriate, lowest-cost setting. Meyer said she is somewhat regretful that it was not executed earlier, and says that a certain home health mindset about physicians may need to change.

“It’s a culture that we have with medical documentation, that we always try to make things easy for physicians, [who] say they’re busy,” Meyer said.

Neither Meyer nor Cameron supports PCR—Cameron went so far as to call it “an evil that needs to be stamped out.” However, while it is ongoing, agencies may be well-advised to not get too defensive, Meyer suggested.

“The very first [pre-claim] I submitted was not affirmed,” she said. “I’m looking at the non-affirmed reason and [the MAC said] it doesn’t appear this patient is homebound. I could see where they could say that, but it’s then going back to the physician, asking them to do better documentation, and then it went through. That’s that quality assurance process … you have to look at it with a very critical eye, not defend it.”

Still, the unpredictability of what is affirmed versus not affirmed seems to be undeniable, and so even with a robust QA process and diligent communication with physicians, perseverance is the name of the game.

“You just can’t give up,” Meyer said.

Written by Tim Mullaney

Companies featured in this article: