Voices from Pre-Claim: Lessons Learned the Hard Way (Part 2)

Click here to read Part 1 of this series.

Home health providers in Illinois now sound a little different when discussing Pre-Claim Review (PCR), compared to the early days of the demonstration project.

Back in August, after PCR first rolled out, agencies in the Land of Lincoln were angry and frightened—angry at what they perceived as the rushed and sloppy implementation of a burdensome and ill-conceived program, and frightened that it might increase their costs and strangle their cash flows to fatal levels. Under PCR, agencies are required to get Medicare auditors’ “affirmation” of their documentation prior to submitting claim for payment.


Providers still are not broadly supportive of pre-claim, and they still are passionate when discussing the demonstration’s flaws. But with affirmation rates rising and administrative processes running more smoothly, some agency leaders sound circumspect about the program and more confident in their ability to meet its requirements.

Four of those leaders—Cheryl Meyer of Advocate Home Health Services, Cheryl Adams of At-Home Health Care, and Dawn Futris and Elenita Abrecea-De Vera of NorthShore University Health System—spoke last week at the Illinois Council for Home Care & Hospice annual meeting in Lombard, west of Chicago.

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They discussed what the experience of being the pre-claim “guinea pigs” was like, offered strategies that they’ve found effective, and shared other lessons learned—all of which agencies in other states might find helpful, as PCR is slated to expand to Florida in April.


This, the second installment of the series, focuses on how these agencies are submitting pre-claims, changes to their workflows, and big-picture lessons learned.

The Process

Adams: We are using eServices [to file pre-claim submissions with Palmetto]. I create a file for each patient, and in the last few months, have gotten it down to about five documents that we submit, depending on a case. It’s working well. We were already scanning some documents into our records, so scanning and all that was not an issue within the organization. Very really MAC interaction because we were at 100% affirmation from the beginning. I’m sorry! [laughs] I’d like to think we’ve got a good process going.

Meyer: I mentioned we use desktop faxing, and I want to qualify why we went that way. CGS never had an eService portal option until this week. So, we could either use the U.S. mail or we could fax. So, we chose to fax. And we didn’t want to have two different processes in our agencies. We thought it would kind of be a toxic environment if we did that. We did start out by putting papers in a fax and faxing. That lasted about two weeks. And then we got the right fax technology, which is a desktop option. What is nice is that when a reviewer gives us their decision, it comes right back to the desktop fax.

In terms of the MAC interactions, CGS had scheduled phone calls with us to review any non-affirmations that we had and to go over them in detail. They would send over codes for non-affirmations, and they were very broad. They didn’t give you the granular detail you needed to fix the problem.

One example I remember is, “You submitted orders that were not signed by a physician.” The signature is right here. They said, really, the issue is we can’t authenticate that signature. They said, that signature on that document doesn’t look like the same signature on this document. Several of the physicians are taking their orders and importing them into an iPad, then they take a stylus and sign 50, 100 at a time. I don’t know about you, but when I’m in a retail store, and I put in my card, and I take that stylus and sign it, that signature looks nothing like my signature if I put pen to paper. So we had to get the physicians to say, yes, that’s my signature, with an attestation statement.

That’s some of the re-work and scrutiny of detail that goes on, and I’m not sure that that’s serving anyone’s best interest.

CGS sent a provider outreach trainer to spend time with us. They were helping us achieve 90% affirmation rate. I would say that that one-on-one education was very good for us.

Futris: We started out 100% … for one submission. Then we rapidly dropped down to around 60%. So we took everything that they gave us, and Elenita came up with a great system. We look at what they say the problem is, and Elenita’s great, she pulls out the regulatory guidelines and maps out each one to see what’s reality. I think what’s interesting, and I’m sure all of you will agree with this, it ended up that we were educating each other. Those reviewers did not know home care. You end up telling them what this means. They might tell you what they want, but you’re the ones telling them where it’s at and what it looks like.

It seemed for so many non-affirmations, they said, you don’t have your therapy goals. They were always there. They’re on our 485, they’re not going anywhere. We learned how to highlight and add notes, so now we know those high-risk areas and we tell them upfront, this is what you want, come look at me.

Meyer: We took our top three non-affirmation codes and actually put them into a work plan. We gave ourselves four weeks to clear up the problem. Surprisingly, one of the codes was the certifying physician identified the wrong community physician. I don’t know if you’ve ever seen that. As far as I know, two physicians could always be involved in getting a patient certified eligible for home health. In fact, they’ve asked for a number of years that we put both those physicians’ names on the claim. I know it can be done. I think there’s some misunderstanding of all the parties on how that’s supposed to work.

A big process modification we made is not trying to get that certification up front from that physician who is doing the encounter. We just take the encounter from that physician, and once they identify the community physician, we have that physician acknowledge that the encounter was done. That’s worked for us. It’s much more smoother, I think.

Adams: This gave us an opportunity to look at our processes and streamline. What we did, at this time, we included our attestation and our certification on our plan of care, so we only had one piece of document going to the physician. We made sure they had all the referral information from the hospital or nursing home that the patients were coming out of, but that was one of the processes that we’ve managed.

Meyer: We established a dashboard that we reviewed at our weekly PCR meetings. We were always looking at our affirmation rate. For an agency our size, we are currently at 88% affirmation for CGS, which for the volume, I’m very proud of. Palmetto we’re at 92%.

One of the metrics that I would like to take back to my group is reducing that cycle time. That’s something I think we don’t have a handle on, it’s so variable. When we started PCR, the average turnaround time to get a signed plan of treatment was about 19 to 20 days. That’s one of the things that is less in our control, but I think a really good thing to look at in terms of shortening the cycle time.

Adams: When we started PCR, our turnaround time [for a PCR submission] was about 14 to 21 days. We’re now at between seven to 10 days. When we get that plan of care done, our clinician has it done within two business days. So, it’s out to the physician by that time. If we’re not receiving that plan of care back within five days, then we’re picking up the phone and calling. And our administrative people are doing the tracking. I’m really proud of that turnaround. Financially, it lessens the burden.

Abrecea-De Vera: We do a dashboard so everyone in the office can walk by and see the number of submissions we have done, the affirmation and non-affirmation [rate]. At this time we’re at 95% affirmation. We’ve had challenges with staffing because of re-structuring, somewhat, in our department. Our PCR team of three to four has come down to two and a part-time person.

One of our challenges is the nursing home and clinic referrals. It’s getting the certification, getting the physician to coordinate the encounter. Most of them are non-NorthShore physicians. But with our hospital physicians, we are between 15-20 days.

Big-Picture Lessons

Futris: Under the crunch to move forward, we didn’t have time to create a work plan. I think that moving forward, we would. I wish we would have defined our elements a little differently. We need a work plan to define what we’re going to do and when it’s going to be done by.

I like that Cheryl [Meyer’s] group made the decision that they’re not going to take a referral unless they’ve met criteria. I think that empowers your intake department. We have not made that decision as of this point. I would at least want to consider something like that in the future.

Meyer: One of the things I would do differently: To hold people accountable, you have to have your processes written down. I think some processes were written down, but many were not, and I think that was an opportunity. And I think doing a risk assessment. Where are you most vulnerable to not having that documentation? For us, it was referrals from physician offices. If patients were in any type of facility, nursing home, hospital, it was easy to secure encounter notes. Not so much from a physician office.

Adams: I think remember that more is not always better. Look at your documentation. Make sure it’s concise, explains the whole story, and you’re making it easy for everyone. You’re not only making it easy to read for the physicians but for whoever is reviewing it as well. Don’t make it so cumbersome that a reviewer or clinician or physician is stumbling through it. That’s a key part of this.

Considering everything, Illinois did really well. I’m really proud of what Illinois did. I explained to Texas when I was down there, you will survive this. We survived this, and we overcame.

Written by Tim Mullaney

Photo Credit: Phil Roeder, CC BY 2.0

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