Ready or Not: Home Health Industry Braces for Pre-Claim Expansion

In what has been described as a cruel April Fool’s Day joke, the Centers for Medicare & Medicaid Services (CMS) announced it will be expanding the Pre-claim Review Demonstration (PCRD) to Florida beginning April 1, 2017.

As the controversial program charges ahead to the Sunshine State, providers and industry advocates have prepared, but are still hoping to find a way out. The decision ends a pause that CMS placed on further implementation earlier this year.

Senator Marco Rubio (R-FL), who urged CMS to pause the program earlier this year with Senator Bill Nelson (D-FL), expressed disapointment with the decision.


“We are disappointed with CMS’s decision to move forward‎ and plan to work with the incoming administration to ensure we address fraud in the system while preserving Floridians’ access to quality home health services,” a Rubio spokeperson told Home Health Care News.

Lessons Learned

There has been some recent good news regarding the program, including higher affirmation rates for pre-claim requests in Illinois, where PCRD has been underway since August 3.


“The Illinois experience has had some positive outcomes,” the National Association for Home Care & Hospice (NAHC) said in a newsletter to its members following CMS’ announcement Monday.

Beyond higher affirmation rates, agencies have started to figure out the PCR processes and can recognize their own documentation weaknesses better, according to NAHC.

However, submitting pre-claim requests has proven to be very time-consuming for agencies, with many dedicating staff to the process full time.

“The Medicare Pre-Claim Review Demonstration has proven to be a costly, burdensome endeavor for Illinois home health care providers,” Bobby Lolley, executive director of the Home Care Association of Florida (HCAF), told Home Health Care News. “In light of federal regulators’ decision to roll out the program in Florida next spring, providers are gearing up to meet this challenge and prove to policymakers once and for all that the patients we serve are eligible for and in need of the high quality, cost effective care that we provide.”

Fortunately, providers in Florida have had time to prepare for the demonstration’s implementation. Thanks to the temporary pause, home health companies in Florida presumably could learn from mistakes coming out of Illinois before they were thrown into the demonstration themselves.

“We have prepared for this,” Andrew Shook, owner of Elite Home Health, told Home Health Care News. “We knew this was coming down the pipeline, and, if it wasn’t this, it would have been the same effort [to deal with] increased audits.”

Elite Home Health is a full service home health organization with multiple locations across Florida.

‘Still a Nightmare’

Despite higher affirmation rates—which reached 87% for pre-claim requests in the program’s 17th week, according to CMS—home health agencies are spending significant time and resources simply executing the submission process. And industry groups have not backed down in their opposition, as not all agencies are experiencing success under the demonstration.

“We are still vehemently opposed to the Pre-Claim Review Demonstration,” the Visiting Nurse Associations of America (VNAA) told HHCN. “While CMS has been able to raise the rate of provisional affirmations, agencies are still struggling with the administrative burden put on them. …This pre-claim review process is still an administrative nightmare.”

NAHC, which recently vowed to file a lawsuit against CMS to put a stop to PCRD, also said it would step up its advocacy efforts, further “aggressively pursuing remedies” for PCRD’s problems. The “vast majority” of improper payments that CMS intends to reduce under PCRD are actually related to issues with the physician certification and face-to-face documentation requirements, NAHC said in a letter to its members.

The Price is Right

While industry groups continue to set their sights on repealing or pausing PCRD, there could be a hands-off solution in the near future in the form of the incoming Trump administration.

Representative Tom Price (R-GA) has been named President-elect Trump’s pick to lead the Department of Health and Human Services (HHS), and he is vehemently opposed to PCRD. With Price in office, a complete dismantle of the demonstration could be on the table.

“Just as I was not surprised [PCRD] came down the pipeline, I would not be surprised if [Price] goes and adds a year of delay or longer,” Shook said. “I’m not going to assume that’s going to happen, but it would not shock me in the least.”

Similarly, NAHC has been bullish that the incoming administration could result in a rollback of regulations.

Written by Amy Baxter

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