[Update] CMS Sets Pre-Claim Start Date for Florida

The controversial Pre-Claim Review Demonstration (PCRD) will expand into its second state, Florida, on April 1, 2017, the Centers for Medicare & Medicaid Services (CMS) has announced.

The move comes several months after further implementation of the demonstration was put on hold. Currently, the program, which requires home health care agencies to submit requests for reimbursement approval much earlier in the care process, is only underway in Illinois.

The model is designed to eventually reach five states—Illinois, Florida, Texas, Massachusetts and Michigan—where the highest rates of improper home health payments are reported.

The demonstration has been ongoing in Illinois since August 2016, with mixed results and strong backlash from the home health industry. PCRD will expand to Florida for episodes of care beginning on or after April 1, 2017, according to CMS.

The agency did not specify when it would expand the program beyond Florida.

While the program does not change beneficiary eligibility standards or documentation requirements, home health agencies in the Prairie State have reported high non-affirmation rates for payment requests and burdensome administrative processes.

The demonstration aims to reduce improper payments by first targeting the states with some of the highest rates of improper payments. In 2015, 59% of home health claims resulted in improper payment, according to CMS, with a large proportion of that due to insufficient documentation.

In addition, the demonstration will ”help educate home health agencies on what documentation is required and encourage them to submit the correct documentation, while still allowing the home health agencies to begin providing services.”

As of December 2, 2016, the affirmation rates for pre-claim requests reached 87% for partial or full affirmations, according to CMS.

April Fool’s?

There may be some hope for advocates looking to put an end to the program with an incoming Trump administration. President-elect Trump’s pick for Secretary of the Department of Health and Human Services (HHS), Rep. Tom Price (R-GA), is one lawmaker who introduced a bill to pause the demonstration.

“Is it a coincidence that it’s on April Fool’s Day?” Laurie Lorch, director of health information management at the Visiting Nurse Association of Florida, told HHCN about the planned start date. “Keep in mind the rumblings of the new Administration regarding relaxing regulatory issues. Stay tuned for the next communication regarding PCR going forward once the new Administration is in place.”

Still, there is no guarantee that the new administration will halt or pause pre-claim, and in the meantime, industry advocates are continuing to push back against the program.

Since August, these advocates have pushed for a delay in implementation, and lawmakers have put forth legislation that includes a one-year moratorium on the program. The National Association for Home Care & Hospice (NAHC) recently said it intends to file a lawsuit against CMS to stop the demonstration.

NAHC set its sights on a more aggressive advocacy plan upon the announcement of the expansion to Florida. The plan includes seeking a suspension/rescission of the demonstration from the incoming administration; introducing legislation to suspend the demonstration in the new 115th Congress; develop its lawsuit to challenge the validity of the program; initiate provider education efforts to improve acceptance rates; and establish standards for CMS to target only high-risk providers.

Written by Amy Baxter

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Amy Baxter
Assistant Editor at Home Health Care News
When not writing about all things home health, Amy fulfills her lifelong dream of becoming a pirate by sailing in regattas and enjoying rum. Fun fact: she sailed 333 miles across Lake Michigan in the Chicago Yacht Club "Race to Mackinac."

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