4 Lessons Learned on the Front Lines of Pre-Claim Review

With the controversial Pre-Claim Review Demonstration (PCRD) set to go into effect in Florida at the start of April, home health care agencies are preparing to be hit with the new requirements. After a bumpy start to the program in Illinois, many home health providers found themselves on a steep learning curve to get pre-claim submissions affirmed.

The program, which requires home health care agencies to submit care documentation to Medicare Administrative Contractors (MACs) much earlier in the care process, has been widely critiqued by the industry. Lawmakers in Florida recently sent a letter to Department of Health and Human Services (HHS) Secretary Tom Price asking for a pause on the program in its current state. PCRD is expected to also be implemented in Texas, Michigan and Massachusetts.

As the program rolls on, there are lessons to be learned from Illinois agencies.


Provide consistent and specific documentation  

A top complaint from home health agencies when PCRD first began in Illinois was non-affirmation results on an inconsistent basis. For some agencies, it was a slow process to learn exactly what information needed to be included and how it should be presented to MACs, such as Palmetto GBA. While PCRD did not change documentation requirements, to avoid delays in affirmation and multiple resubmissions of pre-claims, agencies in Illinois found themselves seeking out the most specific directions possible from all resources.

“We learned we had to get a good understanding of what the reviewers were expecting to see in the documentation,” Rachel Hecox, director of nursing at Western Illinois Home Health Care, told HHCN. “We relied heavily on the calls from Palmetto to give us specific directions on the submitted docs. We also relied on the weekly calls with the National Association for Home Care & Hospice (NAHC) and the Illinois Homecare and Hospice Council to give us guidance to handle these issues, and also really just to commiserate with other home health colleagues.”


Reasons for non-affirmation rates varied greatly for agencies, but being as specific as possible on documentation upped the chances of getting pre-claims affirmed sooner.

“There is a lot of room for interpretation, as far as what they are requesting in medical records,”Hecox said. “It was through trial and error, a lot of back and forth, to drill down to what was expected.”

Get management on board

PCRD is a major change for home health agencies in the way they process claims—and, with a direct threat to reimbursement rates, it’s essential that compliance comes from top management all the way through the business.

“A lesson that stood out for me the most is that the agency has to have strong leadership and be able to manage change,” Marvin Javellana, CEO and founder of Better Care Home Health Inc., a home health care agency based in Des Plaines, Illinois, told HHCN. “I believe that most owner/operators have the clinical and regulatory knowledge that is required by PCR. What most struggle with, including us, is the ability to get everyone in the same page on these changes for effective collaboration and implementation of PCR.”

While clinical staff are the ones submitting documentation—a lengthy process by some accounts—leadership needs to be on board to facilitate the transition of the way the business is run.

“Change has now become a constant in healthcare at a more frequent rate,” Javellana said. “My advice to the agencies that are in the PCR states is for the management team to brush up on their Change Management skills. This will be a good place to start in order to lessen the anxiety of PCR.”

Educate physicians

Another top concern from agencies in Illinois was dealing with physicians under the program. Specifically, agencies that needed documentation and signatures in a timely manner from physicians found that, with little skin in the game, doctors offices weren’t totally prepared for the added burdens.

However, working with physicians more closely and educating them about home health requirements improved the relationship for some agencies, according to Katharine Eastvold, director of regulatory and government affairs at the Illinois HomeCare and Hospice Council.

“Educating the physicians is one key that would apply across the board,” she told HHCN. “Agencies need to develop that relationship so that the physicians not only understand the process, but also that it’s imposed on the entire state. Many have been understanding.”

Have the right staffing structure

Submitting PCRD documents is a process in itself that took longer than the Centers for Medicare & Medicaid (CMS) estimated, according to reports in Illinois. For some, each pre-claim submission took up to an hour. As such, many agencies, including Western Illinois Home Health Care, hired a full-time employee to keep up with the PCRD requirements. However, others found success simply by taking a look and reorganizing their staff structure.

“There was a lot of variety among the agencies,” Eastvold said.

While many agencies struggled to comply with a steep PCRD learning curve, not all critiques of the program are negative. For instance, any bad apples unable to comply with the program could shut down and open up recruitment opportunities for legitimate providerssays Javellana.

“Although PCR is challenging at first, it also brought to light the agencies that were not legitimately doing business,” he told HHCN. “Most of them went out of business or [are] in the process of going out of business. This means more pools of potentially good clinicians are available in the market. It will drive the very high per visit rate in Chicagoland down for per diem clinicians (compared to other states like California, which has a higher cost of living).”

Written by Amy Baxter

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