It is no easier to find something positive to say about the CMS Pre-Claim Review experiment in November than it was in August. This conclusion follows conversations with Illinois providers, a BKD managing director, NAHC's Bill Dombi, and a Palmetto GBA staffer.
Dombi announced at last month's NAHC meeting that he is preparing a lawsuit to force CMS to stop Pre-Claim in Illinois and not start it up in Florida, Texas, Michigan and Massachusetts until such time as its contractors can get it working properly.
He also pointed out that the volume of review requests that seem to have already overwhelmed the capability of PGBA reviewers to keep up is a fraction of the total number of RAPs sent from Illinois since August 3.
This was confirmed in a November 4 CMS report. "Between August 3 and October 31, 2016, CMS received 23,061 pre-claim review requests from Illinois Home Health Agencies. In the same period of time, CMS received approximately 80,961 RAPs."
Reminder: the 25% penalty for submitting a final claim not preceded by a pre-claim review began on November 3.
These numbers are the same that BKD is seeing. Managing Director Aaron Little has been helping Illinois clients cope with the requirement. He told us that some agencies are sending a handful, as few as 10% of their episodes, in order to test the waters until they learn exactly what PGBA reviewers are looking for. Their intention is to make adjustments before they send the rest but they are still finding that some reviewers interpret the rules differently from each other. Dombi's August comment that some of them make determinations based on rules that do not exist is still valid as well.
"What are they going to do with the current number of reviewers when the volume from Illinois grows tenfold?" Little asked, "Not to mention after they expand to Florida and Texas, both of which are also the responsibility of PGBA?"
Indeed, many people are questioning the wisdom of funneling the first three states, big states, to one MAC instead of starting PCR in a more sensible order that would spread the work across the three MACs that serve the five pilot states.
60 Days of Reviews
CMS reported the first 13 weeks of Illinois Pre-Claim Review results on November 4. The report shows an affirmation rate of 45% in week 2, a dip to about 41% in weeks 3 and 4, then a slow, steady climb to 83% in week 13, with a brief plateau at 60% in weeks 6 and 7.
These affirmations include "provisionally affirmed" and "partially affirmed" decisions in the tally. There is no category called "fully affirmed." All requests that are deemed payable are called "provisionally affirmed decisions" pending the quality of the final claim. Claims can be denied even if the pre-claim request was affirmed.
According to the report, "A partially affirmed decision indicates at least one service was provisionally affirmed."
We've got it handled
According to Palmetto (the individual in the PGBA booth at the NAHC meeting did not want to be quoted by name), things in Illinois are "going well." The pre-claim affirmation rate has climbed from 20% to 80%, they are re-allocating trainers from Florida back to Illinois to teach providers there how to submit better documentation, and they have plenty of well-trained reviewers ready to handle the growing load. He said all these things with a straight face.
"Wait, wait, what?" came a voice from Peoria, Illinois. Tarrah Gruber attended a Palmetto training session for Spoon River Home Health. She told us one of the two trainers, the only one that was a registered nurse, was herself a trainee, with three months on the job. The senior trainer, not an RN, had been with PGBA for 8 years, but only recently returned from an extended leave for family obligations. The two trainers were so unfamiliar with CMS Home Health rules that they had to call HQ, during the training session, in order to answer questions posed by the audience of veteran agency owners.
Ms. Gruber confirmed that PGBA is reporting an 80% affirmation rate but noted that CMS will not discuss what percentage of partial affirmations is included in that number. According to Dombi's explanation, this means that CMS would consider PCR a success, and justify extending it from pilot program to national rule, even if more than half of Illinois' "provisionally affirmed decisions" turned a $3,000 claim into a $300 payment.
CMS has not announced a start date for Pre-Claim Reviews in Florida and Texas, which most assume will not start together but will precede Michigan and Massachusetts by several months. Questions facing CMS on that future date, which will come with a 30-day warning, center around PGBA's ability to handle the volume. As mentioned above, Illinois has submitted only 28% of its episodes for pre-claim review in the first 60 days of the pilot. At some time between now and when Florida and Texas begin, Illinois will begin to release the rest of its 57,900+ episodes for review. "They have to," BKD's Aaron Little told us. "They cannot survive without cash flow for much longer, and they do not dare risk the 25% penalty."
Illinois has just over 750 home health agencies. When Florida comes online, more than 1,100 will be added to PGBA's workload. Texas will bring another 2,500. Providers in those two states are already expressing concern, wondering how PGBA's army of trainees will be able to process, with accuracy, more than 20 times as many requests as they have seen so far.
Bill Dombi announced last month that he will try to force CMS to delay the Pre-Claim Review pilot until its contractors are better able to execute it. This sounds like one suit that CMS will be relieved to lose.
©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