As we continue to keep readers informed about the impact of CMS's Pre-Claim Review pilot, we spoke this week with two software vendors, a CMS connection service provider, and two consultants, one a financial advisor and the other an appeals resolution specialist. We believe we are getting a handle on the pros and cons of the new rule but reserve the right to update our analysis as more details come to light, especially after we interview HHAs in the first pilot state, Illinois, when the rule kicks in sometime in August.
Software leads off
EMR software vendors are the first to be affected, whether they have a hundred. Software updates must be made across the board even if they only have a few customers in the five states in the pilot. The basic framework of the changes they need to deliver to the customers are in place but CMS will not tell them until June 28 what the final details will be. For example, in their June 14 conference call, CMS representatives were taken aback when a questioner pointed out to them that the 837 field they want to use to hold the pre-claim approval number when submitting the final claim is a field that is already used for another purpose. "We'll get back to you on June 28 about that," they sputtered, unable to disguise the embarrassed tone in their voices.
"Here's what you have to understand about how vendors handle regulatory upgrades," explained Delta Health Technologies' Bill Bassett. "There are always going to be changes, whether it's the Comprehensive Joint Replacement payment bundling that was announced six months before its implementation date or this one, which only gave us a six week warning. You have to read the tea leaves and be prepared for anything. If you are light on your feet, by which I mean you have SaaS or web-based software, you make the change and all your customers have it that day. The vendors who will struggle with getting the details on June 28 and having them ready for Illinois customers by August 1 are the ones with legacy, client/server systems on 20 year-old database technology."
Connectivity up second
Providers of CMS connection services have to make August 1 changes as well and are anxiously awaiting the rest of the story CMS promised to deliver on June 28. We spoke with Ellie Robison, CEO of MedTranDirect, who told us it will make a big difference whether an unused field can be found on the 837 form to insert the pre-claim approval number or whether the form will have to be redesigned.
"We are ready to update our product that transmits and receives 837 and 835 documents," she said, "and we would like to be able to transmit the stack of pre-claim documents. There are a few questions that have to be answered before we can do that though."
She is referring to the way the CMS representatives dodged the answer to a question during their June 14 Open Door forum. When informed that the field on the 837 form they told HHAs to use is already used for another purpose, they muttered, "We'll let you know about that on June 28," failing to disguise the embarrassment evident in their tone of voice.
When asked whether plans of care have to be signed by the physician in time for the pre-claim submission or can wait until the final claim, as is the rule now, the answer was again profoundly unclear. "No other rules are changed," was the best they could do when confronted with the unexpected question. No one we spoke with is sure exactly what that means.
Batting third, HHAs themselves
Nothing made it more clear that CMS is unfamiliar with the day-to-day challenges of operating a home health agency than their cavalier non-answer to the signed plan of care question. Every agency administrator knows the fiasco that occurred when physicians were required to certify homebound status under the Face-to-Face rule. Failure to get it done, signed, and correctly worded caused a phenomenal number of payment denials that could not be avoided or repaired by the agency itself.
The same resentment regarding perceived unnecessary encroachment on their time crops up among physicians when asked to review and sign plan of care documents. Most providers have difficulty getting them signed by the end of a 60-day payment episode so that they can submit a final claim. If MACs interpret the new rule as meaning they can deny a pre-claim review over a missing signature, which is possible if CMS leaves the question unanswered, HHAs will have to bug physicians to sign the document at the beginning of an episode.
"They are not going to like that," asserted Deanna Loftus, Director of Regulatory Compliance for HEALTHCAREfirst. "We provide outsource billing services and electronic document signing as well as EMR software and we know firsthand that the primary billing delay is the physician signature. Getting it 50 days sooner than they do now will be extremely difficult."
Cleanup: the consultant's overview
"What took them so long?" was Michael McGowan's surprising reaction. "Over the years, I have seen so many fourth, fifth, and sixth consecutive episodes for low-acuity patients, I finally got to the point where I wondered why CMS wasn't seeing the same thing. This new rule forces agencies to play by the rules. It will be good for the patients, good for the tax payers, and good for the high-performing HHAs."
The former OASIS coordinator for CMS Region IX and now a payment denial consultant and designer of OperaCare, a new software tool designed to produce perfect, audit-proof episode documentation, McGowan offered this bird's eye view of the environment the Pre-claim approval rule is trying to improve:
"There are more HHAs than the population numbers require. With supply outstripping demand, many HHAs are suffering with census numbers too small to sustain payroll and overhead. There are two ways to keep census numbers up: find new patients or keep the current ones. With every sales rep finding his or herself one of ten or twenty hitting physician offices every day, winning new patients is hard. Recertifying patients, no matter how unjustifiable in terms of medical necessity and homebound status, is much easier."
This cause-and-effect logic string that McGowan describes is coming to an end, at least in the five pilot states, and is becoming the primary focus of attention for MAC auditors in every state. "These are the states that are the worst offenders," he told us, "so controlling the problem in 10% of the states will solve much more than 10% of the problem.
"Here is how it will happen. Agencies that have been surviving on recerts will see most of them disapproved in the new pre-claim process. They will perceive this as MAC overreach but that will mostly not be the case. These are episodes that should not be paid. Unable to be paid anymore to care for relatively healthy patients, their census will shrink and they will either figure out a way to improve their sales results or they will close or be acquired. The ethical agencies that have been discharging patients when they should will see few if any of their episodes disapproved for lack of medical necessity through the new pre-approval process. They will be the survivors. They will pick up patients from the agencies that close or from the struggling agencies they acquire. In the end, the smaller number of HHAs will match the population demand and everyone left will have enough census to stay afloat."
This consultant is not alone in his analysis that there could be an upside to the rule. We recruited an Illinois agency to keep us informed through the August launch. Susan Platt's opinion of the new rule mirrors Mr. McGowan's.
"We agencies who are working to do it right, to get the face to face documentation correct and signed, to ensure our clients are truly homebound and have a skilled need, we abhor this rampant fraud and abuse. So we understand the idea behind this new rule. I am sick to death of trying to compete against agencies who see patients forever, sign them up for med set ups, etc. Since this new rule isn't supposed to create a barrier or delay in starting care, the concept of stopping agencies who sign up inappropriate patients is great."
©2016 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan's Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. firstname.lastname@example.org