Results from Pre-Claim Review in Illinois

Home Health Care News sponsored a recent webinar to examine the effects of CMS’s controversial Pre-Claim Review (PCR) pilot project. PCR began in August 2016 in Illinois, and threw the home healthcare industry into turmoil.

The webinar included among its panelists Scott Pattillo, Chief Strategy Officer for Homecare Homebase. The company has now published a comprehensive summary of the webinar findings: The State of Pre-Claim Review: A Report From Illinois.

Here in brief are some highlights from the article.

Agency Workload

Panelists were clear that home health agencies experienced a large impact from PCR documentation requirements. The added paperwork and information-gathering forced agencies to hire more staff, as well as to raise the skill level involved. As the article states: “This isn’t just routine paperwork that clerical staff can handle; many agencies have to place nurses in those jobs instead of lower-skilled employees.”

Other problems arising during the pilot included delayed payments when a claim was denied. This caused cash-flow difficulties as well as adding even more administrative workload to resubmit the claim.

Interaction with MACs

Webinar panelists cited lack of communication with Medicare Administrative Contractor (MAC) reviewers as a major obstacle in the PCR pilot. Over time, CMS added codes to explain causes of denial, but the real breakthrough occurred when MAC reviewers were allowed to contact agencies before denying a claim.

With dialog between agency and MAC, reviewers were often able to reverse a denial decision before sending the formal letter of denial – thus saving more paperwork steps and anguish.

And anguish was certainly the result for many patients during the pilot, because denial letters sent to agencies were routinely copied to patients. This led many patients to believe that Medicare payment for their treatment was being disallowed, and even caused some to cancel their service in that mistaken belief.

Physician Roadblocks

Doctors too were frustrated by the lack of training for PCR procedures. Healthcare agencies were forced to spend time and effort to educate doctors and hospitals about the documentation.

Panelists report that this lack of training hasn’t been addressed for the expanded pilot into Florida.

How to Improve PCR

Software may help agencies perform PCR’s heavy lifting. Pattillo from Homecare Homebase said that automated submissions were his company’s focus. All panelists agreed that software tools to structure and unify PCR workflows will be a key to a streamlined process.

The Future of PCR

The webinar panel concluded that overall PCR had acted as a drag on care delivery and payment in Illinois. Panelists strongly felt that CMS should re-evaluate PCR as a tool to curtail fraud – so far no evidence has surfaced to show that PCR actually works.

Meanwhile, the pilot continues to roll out and states should be prepared, warns the webinar panel. Streamlining internal procedures and reaching out with information to doctors and other providers will help buffer the shock of the pilot coming to your own state. But overall, industry experience finds nothing to cheer about in Pre-Claim Review.

A long-form version of this article originally appeared on the Homecare Homebase blog. To read the full article, go here: The State of Pre-Claim Review: A Report From Illinois.