Evidence continues to pour in from Illinois that CMS's Pre-Claim Review pilot is devolving into utter chaos. Pre-Claim auditors at Palmetto GBA issue conflicting decisions, give out inaccurate advice, and change their minds about what the rules are from day to day. The frustration building among Illinois home health providers is approaching the boiling point, with some deciding to clear out their filing cabinets and send to PGBA every piece of paper generated about every patient with every claim, just in case.
Some, not all, getting calls
With the denial rate still near 80%, auditors have begun to call some agencies to tell them when a pre-claim request is going to be non-affirmed and what additional documentation is needed. There seems to be no pattern to which agencies get a phone call and which do not. Astoundingly, these requests often include documents that are clearly not required by the regulations. Illinois agencies have developed profound doubts about the training PGBA auditors received and wonder why that training seems to be different from one reviewer to the next.
Changes every day
Even more astoundingly, one reviewer actually admitted to an agency biller, "They are making changes every day. I may hear about more changes as soon as you and I hang up the phone."
OASIS with a claim?
One provider wrote on the Illinois Association for Home Care listserv that she had a reviewer explain her pre-claim was going to be non-affirmed because she had not sent the OASIS document. "This requirement is a new change that was just made," she was told, "but we haven't gotten the word out yet."
When the agency compliance supervisor explained to the reviewer that OASIS is sent to CMS with a Request for Anticipated Payment (RAP), never to the payer with the claim, so it cannot be required with the pre-claim, she was told that PGBA now "requires the OASIS too in order to make sure the clinician actually went out to see the patient." "I had already sent them all the nurse's visit notes to date," she wrote, in all caps.
Utter fraud prevention fail
It certainly appears as though PGBA reviewers are unaware how easily criminals can produce fake OASIS documents but that weeks of nursing notes take too much time to invent, so fraudsters typically do not bother.
Web site no help
Reviewers appear to have received just enough training to know enough to be dangerous but not enough to understand how CMS and PGBA are supposed to work. It does no good to ask them questions that go beyond the quick, superficial training they received after they were hired over the summer during the CMS-funded staffing up.
One provider wrote to the Illinois listserv that she asked a reviewer why all these important changes are not on the website, the reviewer said, "I do not know." A quick check of the PGBA web site shows the most recent update was on September 7.
One staffer's assessment
With total frustration on display, an agency biller wrote, "So, what they are saying is that they don't really know what they want but they are OK with us putting in the extra time guessing what to send them. In the meantime, patients have to suffer when we are reluctant to provide services we will never be paid for. All because they have no idea what they are doing. I know what I'm going to do. I am going to re-submit everything, including OASIS and nurse notes, for every non-affirmed patient, every time. Then let them call me about what is missing. THIS IS CRAZY."
©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