Voices of Pre-Claim: Lessons Learned the Hard Way (Part 1)

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.

The Preparation


Meyer: What I remember about the summer of 2016 was that it didn’t seem like summer at all.

We pulled together a PCR task force. It was chaired by our VP of finance. He has, and still has, ultimate accountability for making sure PCR works at our agency. We have weekly meetings, and it involves a multi-department approach. I’m on there for the regulatory piece.

I think that was all critical to our success. It starts at intake, all the way until you file that claim. We had all those people involved. But I can tell you, during the summer, there was always somebody on vacation. We had to get through that period … I think our prep was really compressed, but I think having that focused task force representing all the departments, I would do the same thing again.

Abrecea-De Vera: Our administration was very supportive. Our president and vice-president of our department have been very involved from the beginning. Our director sends a benchmark or dashboard to the finance team and executives bi-monthly.

From the office staff standpoint, we make sure that everyone receives a newsletter with regard to PCR. Intake is the hub of the organization, so pretty much we’ve tried to re-educate and make sure that certain pieces of the requirements, that they understand the process. We’ve signed up for so many webinars … every single webinar that CMS posted. There’s like two or three meetings a week.

Futris: One of the things I found interesting in all those PCR classes we went to is that they said, “We’re going to educate the physicians.” … I will say that I was part of a group with our hospitalists, the head of our residents, a whole group of physicians—in July—and I was taking them information from Palmetto. The doctor looks at me and says, “I don’t want this. You just tell me what to do.” I think that’s what a lot of our doctors are feeling. There was no opportunity to educate them per se, which is why we decided to build the elements exactly like Palmetto said and put them directly into our referral. That was our education.

We also worked on communicating with our field staff. We brought them in for two separate sessions. Each time, we brought them in in small groups, so we could actually talk. We told them about the financial impact that this could have on us. About the regulations. And how what they did mattered. We asked our staff, what do you think is pertinent that will help prove the case that these patients are homebound and need skilled services, and we incorporated that into our smart text that got sent to the physician for signature.

We did not educate our patients. We were so overwhelmed ourselves. Every week, we heard something different from Palmetto. We didn’t have the opportunity to teach our patients anything, but we told our staff, “We have been told that your patients may get letters, you can talk to them about it.” We never got one phone call from a patient. I don’t know if they just didn’t get the letters or didn’t read them.

The Technology

Meyer: There were a lot of technology challenges. We just have to think back to the fact that we had about six weeks of prep time. Our particular vendor, they were working with us and had weekly phone calls with us to make sure that they understood exactly what we were going through. I think they were using us, because we were in Illinois, as kind of a planning opportunity for what’s going to come in the future.

Our biggest challenge was identifying the patients that were ready to send the documents in for PCR. You have to have your orders signed, your face-to-face documentation in, your OASIS transmitted. Just getting a workable report that we could filter and plan to send our PCRs out, that took a while. Until that was ready, we were working from a spreadsheet. We couldn’t wait for the technology to catch up to our needs.

There might be some of you still on paper documentation systems, but if you’re in an EHR, you’re in a hybrid situation. You have your electronic health record for your billing and point-of-care documentation, but there’s usually another system where you’re storing all your documents. It was managing documents in two different places. We were never able to use eServices with Palmetto and are still not using it to this day because of the way our documents are stored. We do desktop faxing.

We also had big differences between our [Medicare] contractors on what they would receive and the decisions they made … That’s one of the things that if I had the opportunity to talk to somebody at CMS, I would say. I was in the demo project when they rolled out OASIS in the mid-1990s. That was a very structured demonstration program. I just don’t feel that was in place because this was rolled out so quickly. That’s why it’s so painful.

Adams: I have to agree that the tracking mechanism was the most challenging at the beginning.

Our EHR has the ability to give us certain tasks to tell us which patients, but knowing when they were ready to go was a challenge. Our EHR is currently streamlining that to get that process.

Our data is all stored within that patient record, so we didn’t have the storage issue. We do send via eService. Most of our documents are already saved as PDFs, which is a requirement of eServices. That was the easy part. The challenge was deciding how I was going to manage the files that we would send, and keep it available for the other clinicians or administrators within our office. They needed access in case Palmetto called. If they called with a question and I wasn’t there. Now we have a process where we have a folder on each patient, and in that folder is each document that we sent for pre-claim. Now, I don’t have a fear of Palmetto calling and me not being there and not being able to answer their questions. We have educated the staff on how to answer those questions and find the documents they need.

Futris: Our EHR did not store files as PDFs. We had to purchase Adobe for the people who were going to be participating. We had to purchase scanners. Those are expensive things to get, especially when you have six weeks’ notice and no one in the office knew how to do this stuff.

I will say I was really impressed with our vendor and our IT team. We were meeting with them it felt like every single day. Our vendor came down and went to one of the Palmetto meetings, because their big question was, “How do you put that 13-digit UTN on the claim when there’s not 13 spaces there?” That to them was very worrisome. Our vendor had a war room, and they were there for weeks.

The other thing we had was that at first, we gave a document for each task. And then it was within a week or two, we got a call back from somebody, and she said, “We can’t read your documentation.” I was like, “What do you mean? I can see it on my screen, it’s beautiful, it’s so clear.” She said there’s something all over it, letters all over it. It ends up that there was something called embedded executables. And it sounds like because of the way we had it saved from our EHR, when we went onto Adobe, it put these in as a security measure. So then we had to take all of those documents and created one document that had everything in it.

We had a lot of challenges, but we came together as a really good team.

(Part 2 of this series, focused on The Process and Big-Picture Lessons, is forthcoming on Home Health Care News)

Written by Tim Mullaney

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