Pre-Claim Affirmation Rates Rise, But Some Agencies Stay on Sidelines

There’s more good news coming from the federal agency that enacted a controversial home health care program that left the industry reeling. Affirmation rates for the Pre-Claim Review Demonstration (PCRD) currently underway in Illinois continued to rise in the program’s 17th week, according to the Centers for Medicare & Medicaid Services (CMS).

Affirmation rates—including claims that were either fully or partially affirmed—reached 87% in the latest data provided to CMS, the agency reported on December 2. Fully affirmed pre-claim requests reached 83%, and 4% received a partially affirmed decision. The rates were tracked through the 17th week of the program in Illinois, which ended on November 26.

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Home health industry groups reported that some agencies were likely holding back some of their pre-claim review requests in the early months of the program’s implementation in the Land of Lincoln. Fortunately, the data reveals that affirmation rates for pre-claim requests are steadily trending up. During the first eight weeks of the program, just 66% of claims were either partially or fully affirmed.

“People are starting to figure it out,” Katharine Eastvold, director of regulatory and public affairs at the Illinois Home care & Hospice Council (IHHC) told Home Health Care News. “But the fact remains it is a very time-consuming process that’s causing a lot of frustrations. It takes time and effort away from patient care. That’s time our agencies and providers could be spending doing what they need to do for their patients.”

However, not all agencies are participating in the model. Data from October reported that less than half of agencies in Illinois were making PCR submissions, according to Eastvold.


“Why there are so many agencies out there that seem to not be doing PCRD is a mystery to us,” Eastvold said. “We haven’t seen an update since October on the number of agencies that file PCR. It was fewer than half of all agencies, and we are asking CMS for an updated number.”

Payment Reductions in Sight

CMS’ high affirmation rates, which have topped 80% since October, were significantly higher than what some agencies initially told HHCN. CMS also noted that affirmation rates vary widely between agencies, with some receiving affirmation rates as low as zero. Some industry groups speculated that as a result of some agencies holding back submissions of all their pre-claim-requests, CMS’ affirmation rates were inflated.

Indeed, CMS also noted that more pre-claim requests were likely to come.

Between August 3—the first day of the model’s implementation in Illinois—and October 31, 2016, CMS received 23,061 pre-claim review requests from home health agencies in Illinois, the agency reported. During the same time period, there were 80,961 requests for anticipated payment (RAPs). A claim submission is eventually expected for each RAP, and providers have until they submit a final claim to submit pre-claim review requests.

“Therefore, it is possible that requests associated with many of these RAPs will be submitted through the pre-claim review process.”

Home health agencies were in a grace period to submit pre-claim review requests through Nov. 1. Should agencies not “choose to take advantage of the pre-claim review process, when the final claim is submitted, it will be subjected to pre-payment review,” according to CMS.

As of Nov. 3, claims submitted without pre-claim approval will be subject to a 25% payment reduction if found to be payable. Unlike the pre-claim review process, claims that are not affirmed cannot be corrected, and agencies would need to appeal denied final claims to seek further review.

Now that the grace period has lapsed, agencies are less likely to be holding back pre-claim review requests, according to IHHC.

“We have not heard from our members that they are holding requests back,” Eastvold told HHCN. “The grace period is over and [CMS] is taking 25% off the final payment if a PCR request was not filed. As far as the agencies we’ve talked to and our members, that’s not what they want. They are really getting through their backlogs and submitting as many claims as they can.”

The latest data comes as advocates have doubled down on their efforts to delay the implementation of the program elsewhere and pause the model in Illinois. Lawmakers could act on the Pe-Claim Undermines Seniors’ Health (PUSH) Act of 2015 during the “lame duck session” before new legislators and the new Trump administration enter the nation’s capital in January.

The model is only underway in Illinois after much pushback from the industry delayed implementation in four other states indefinitely.

“Ultimately we would like to see the program suspended or terminated,” Eastvold said. “In the meantime, we would like to see CMS take a look at the data and the agencies that are doing PCR that have gotten the hang of it. Then there is a cohort that aren’t doing it at all for whatever reason, and maybe they could look at targeting that group. It’s a huge burden on our members, but also the tax payer.”

Written by Amy Baxter

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