by Tim Rowan, Editor
While most of the blame for Palmetto's 80% denial rate in Illinois can be laid squarely at the feet of PGBA reviewers who have not been adequately trained in Medicare Home Health regulations, providers of Medicare healthcare at home services must accept that many of the pre-claim non-affirmations are justified. One of the responsibilities that accompanies the privileges of a professional license is to take as much care with the documentation that describes your care as you do with the care itself. With all its problems, Pre-Claim has shown that much more care is needed.
This publication has never been shy about discussing the clinical documentation crisis in Healthcare at Home for Medicare beneficiaries. Whether it is caused by clumsy software or excessive productivity expectations or inattentive clinicians, consultants and Medicare officials have long complained to us that clinical documents frequently fail to show medical necessity for many of the services we offer.
Now we have additional confirmation.
In a conference call with Illinois providers and the Illinois Homecare and Hospice Association this week, NAHC's Bill Dombi made it clear. After speaking about Pre-Claim Review errors that are caused by PGBA reviewers he was quick to add, "We are also finding HHAs could be doing a better job. I don’t know how well you are screening documents you send but the ones you send to us are often absolutely deficient. You have to redouble your efforts to review your documents before you send them in. [Problems include] simple things such as missing dates and the like."
While the bulk of this week's Home Care Technology Report is devoted to calling CMS and PGBA to higher standards, we cannot leave the impression that all the blame is on the other side. Complete, bullet-proof documentation, which only results from setting high employee standards and providing frequent, comprehensive training, has long been an elusive goal in our field. If there is one good that has come from the pre-claim fiasco in Illinois, it is that it has exposed just how sloppy and unprofessional we can sometimes be.
We heard many comments this week expressing the hope that pre-claim reviews will weed out the criminals from out midst. There is just as much chance it will weed out honest agencies that fail to get their act together and start submitting documents that demonstrate homebound status and medical necessity, the two red flags pre-claim auditors and ZPICs look for first.
There are only two ways this situation can be fixed.
One solutions is to take Dombi's advice and redouble our efforts to become more professional with the documentation we produce, review, and submit. The other solution is that problem HHAs will not be able to survive the next &mdash hopefully well-oiled and functioning &dash pre-claim system when it goes nationwide.
One provider on this week's conference call reported a 61% PCR affirmation rate. Not ideal but certainly better than the 20% - 40% average affirmation rate across the state. So it can be done. The ones who do it are the only ones who will be making payroll and keeping the lights on a year from now.
©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