by Tim Rowan, editor
Medicare certified Home Health Agencies in Illinois are furious over a report CMS posted on its web site on October 5. HHAs in Florida and Texas are not yet furious but are experiencing growing concern. NAHC has already released an official response, in which it criticizes CMS for cherry-picking and manipulating data to make it appear as though the experiment is succeeding when it is not. Read the CMS report here.
What is the real denial rate?
In a document simply titled "Fact Sheet: Pre-Claim Review Demonstration for Home Health Services - Early Data from Illinois," the uncredited author declared that, as of week eight, 66 percent of pre-claim requests are receiving provisionally affirmed or partially affirmed decisions.
"Partially affirmed" means partially denied, wrote NAHC's VP for Legal Affairs, Bill Dombi. "The financial impact of partial affirmations can be significant. For example, if an HHA submits a pre-claim review for a plan of care that would result in a $3000 episode if fully accepted, it can result in a partial affirmation with only $300 of the physician-prescribed services approved. It is crucial to understand specifically what the distribution of full affirmations and partial affirmations is in the PCR data along with an understanding of the financial impact on the claim payment amount as HHAs are incurring the full cost of the services rendered." The CMS document does not include this data. Read the complete NAHC response here.
Comparing apples to bicycles
Dombi expresses dismay that CMS counts these partial affirmations when it declares the overall denial rate is only 34%. CMS said, "This suggests that the home health services in Illinois submitted in pre-claim review requests under the demonstration are meeting Medicare rules and requirements at a higher rate than was measured for services submitted in claims in the 2015 national improper payment rate for home health services (59 percent)."
Dombi countered, "It is also notable that CMS presents the proverbial apples to oranges comparison by noting that the non-affirmation rate is lower than the 2015 national improper payment rate of 59%. The 59% calculation is based on the amount paid for home health services that the CERT evaluation concluded should not be paid. It is the ratio of the total dollar improperly paid to the total dollars paid. The 34% metric in the CMS report is a ratio of total pre-claim submissions to pre-claim submission non-affirmations. These are completely different calculations. What is worse, Dombi's reply adds, even if the non-affirmation rate is only 34%, that translates to $350 million per year in unreimbursed care in Illinois. With average profit margins in single digits, providers cannot withstand such losses. Their only logical survival strategy is to delay care until they receive a pre-claim affirmation. This, he says, will result in physical and financial harm to patients and skyrocketing hospital readmissions, further damaging the health of the Medicare Trust Fund.
"PCR is a direct barrier to care access. HHAs with a 34% rejection rate restrict patient admission and delay the start of care until an affirmation is received. Further, patients subject to a PCR rejection self-terminate care to avoid a financial liability for future care. There is a high risk that such patients end up in the hospital when their condition deteriorates from lack of needed home health services." [emphasis added]
How efficient are PGBA reviewers, really?
CMS patted itself on the back with its calculation that decisions are delivered within the proscribed timeline (10 days for first submissions, 20 days for re-submissions) 99 percent of the time. But Dombi reminded CMS that most Illinois providers are holding back most of their pre-claim requests until they have learned from mistakes — both theirs and those of Palmetto GBA — uncovered in early submissions. While the quickly-trained PGBA reviewers are barely keeping up with the volume of work in these first eight weeks, no one know what will happen when Illinois turns loose its full onslaught of an estimated 25,000 review requests per month, nor when Florida and Texas are added to PGBA's workload.
Illinois providers we spoke with, who asked not to be named, wondered aloud which Illinois CMS is talking about, "because it is certainly not the Illinois I live in."
Providers continue to report that:
How much time does each request really take?
The CMS memo also declares: "the time to complete each submission through the online portal decreased from an average of 12 minutes in Week Two to under 9 minutes in Week Eight. This time does not include the time a provider uses to collect the documentation since providers are required to collect this information whether or not the demonstration is in effect."
[Illinois providers tell us reviewers are demanding OASIS assessments and an array of documents common to ADRs, not the smaller set of documents required with routine claims.]
Dombi added his own reaction to those of the Illinois providers to whom we spoke:
"The CMS data is highly misleading. It does not include the extensive time needed to collect the documentation for submission nor does it include the time it takes to review all that documentation for compliance. While CMS is correct in stating that HHAs have the responsibility to collect this documentation, its assemblage, review, and submission is a new requirement under the demonstration project. An HHA study shows that the new functions take nearly one hour of nurse time per pre-claim review submission, not just the 9-12 minutes online."
Susan Platt, owner of Spoon River Home Health in Peoria told us her next steps. "I am going to write and thank all of my congressmen and women for signing on to the letter to CMS. But, I will also add my disgust with CMS and suggest perhaps they need an audit if they can send a report out like that with such false figures."
Our Editorial Position: There must be a 50-state response!
Taking a cue from Ms. Platt, going directly to Congress may be the only hope at this point for HHAs in Illinois, Florida, Texas, Michigan, and Massachusetts. Elected officials do respond when the argument points out that patients are being harmed. However, if CMS is not persuaded by Bill Dombi's fact-filled and thoughtful analysis of their distorted report on pre-claim progress in Illinois, and if they prove immune to pleas from one state's Congressional appeals, there is no doubt that they will proceed full-speed ahead to move from five-state pilot to national rule.
If this is the likely result, every provider in every state has a vested interest in sending a message to their own Congresspersons and Senators. Waiting until this badly executed program arrives in your state will be too late.
With Apologies to Germany's Reverend Martin Niemöller (1892–1984)
First they came for the Illinoisans, and I did not speak out — because I was not in Illinois. Then they came for the Floridians, and I did not speak out — because I was not in Florida. Then they came for the Texans, and I did not speak out— Because I was not a Texan. Then they came for me — and there was no one left to speak for me.
©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