Home Health Groups Encouraged by CMS Response on Pre-Claim Review

For providers, advocates and industry groups that worked and lobbied for an intervention for the Pre-Claim Review Demonstration (PCRD or PCR) to be changed, the pause in Illinois and delay in Florida announced last week is something to celebrate.

However, another bright spot has appeared following a meeting on March 28 between CMS officials, Administrator Seema Verma and home health stakeholders—an open dialogue that could help ease other regulatory burdens down the line.

CMS Responsiveness 


Despite wanting more clarity from CMS and the Medicare Administrative Contractors (MACs) on the pause of the demonstration and potential changes to the pilot, a newfound dialogue with CMS under the leadership of Verma and Health and Human Services Secretary Tom Price has some excited. The positive attitude stems from the meeting that included home care groups and other stakeholders, including three providers from Illinois and three from Florida.

“As providers, we want the fraud to be caught, but we can’t have bureaucrats making all the rules,” Dennis Heide, owner of Florida-based Pinnacle Home Health and an attendee at the meeting with CMS, told HHCN. “Verma said in her confirmation hearing she wanted to engage stakeholders from the beginning. I hope she does that and we can continue to get to the table. That was my takeaway from the meeting; it was really effective.”

Florida agencies and home health groups were some of the strongest opponents to PCR. Its U.S. Senators, Marco Rubio (R-FL) and Bill Nelson (D-FL), both wrote to CMS numerous times to urge the agency to delay implementation in the state and reform the program to be less disruptive to business and care.


The vocal opposition paid off for the state, and three providers were invited to attend the meeting with Verma last week to discuss their experience preparing for the demonstration. They expressed that the state is already strained under the pressures of other mandatory pilots, including value-based purchasing and bundled payment models, and has become a target as a result of a high improper payment rate.

Adding another pilot program to the mix could make it unclear which demonstrations were having a real impact on spending and quality of care, according Heide.

“To put another pilot on top [of others] would be ridiculous, because you can’t tell which pilot does what, and we can’t focus on the pilot they want us to,” Heide said.

In the meeting with CMS, Heide stated this position for Florida and was encouraged by the response.

Illinois providers—who have been participating in PCR since it began in August 2016—had a different story to tell Verma.

“They explained that even though their affirmation rates were high, the process that they had to go through was costing them a lot of money and a lot of clinical staff time,” Sara Ratcliffe, executive director of the Illinois HomeCare & Hospice Council (IHHC) and attendee at the meeting, told HHCN. “It takes away from being able to do the next step of improving quality because they are pushing papers rather than focusing on where they need to.”

Being heard—and seeing action taken—by CMS left stakeholders feeling positive that the program could undergo reforms with providers’ input in mind.

“I was overall encouraged by the new administrator’s willingness to listen to us,” Ratcliffe said. “I think it’s really positive that she wants to understand what home health agencies are going through. We made it clear that we don’t have any opposition to having measures on program integrity, but we think there is probably a different way to go about this than PCR.

The push to delay, pause and change PCR was an all-out effort by home health care providers, industry groups and lawmakers in affected states.

The responsiveness by Verma has been “encouraging,” according to Bill Dombi, vice president for law at the National Association for Home Care & Hospice (NAHC), who also attended the meeting with Verma.

“That [CMS] initiated the meeting adds a very positive element to it all,” Dombi told HHCN. “They have been engaged in the issue. It I were to summarize the meeting, they are open-minded and looking to find reasonable alternatives to PCR with the outcome in mind of driving down the improper payment rate.”

Written by Amy Baxter

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