by Julianne Haydel
Imagine if every one of your Face-to-Face documents and plans of care were scrutinized prior to payment. Would 90 percent of them be found compliant with existent rules? If a non-clinical person determined that your documentation did not meet Medicare coverage guidelines, would you take their word over your nurses'? How would you feel about submitting a perfectly valid claim for eligible services and being paid 25% less than your peers?
Agencies in Illinois do not have to use their imagination. It is already happening through the Pre-Claim Review process. This process involves submitting plans of care, face to face documents, physician and hospital notes and sometimes more to Palmetto prior to dropping a claim for "affirmation." Once affirmed, a secret code is given to the agency which is placed on the claim. Without the code, final claims are reduced by 25 percent.
While Medicare is reporting a 90 percent "affirmation" rate, it does not report that there were over 80,000 RAPs submitted but only 23,000 final claims. Agencies are apparently reluctant to submit their pre-claim review documentation.
Overwhelming burden looming
Because a RAP will be taken back after 120 days if not answered by a final claim, I expect that many agencies are going to drop an enormous number of claims in the coming weeks, which means the number of pre-claim reviews will far exceed what Palmetto GBA is prepared to handle. Maybe Palmetto really can process an additional 60,000 reviews without any interruption in services to the rest of us. Maybe; but I doubt it.
In April, Florida will come on board. Texas, Michigan and Massachusetts will follow at undetermined dates. Agencies in states other than Illinois might not be impressed with all this stuff and nothing. They are busy with the changes to the OASIS data set, the impending Conditions of Participation and perhaps their own audits or surveys. Hopefully they will take pause and consider the magnitude of this demonstration project to understand the egregious nature of this intrusive and burdensome little project taken on by Medicare.
No good deed goes unpunished
The new conditions of participation expected in July of this year explain that prior Conditions focused on identifying agencies with poor performance. The updated Conditions of Participation take a much-needed step away from this punitive approach. As written in the new regulations:
"Ensuring quality through the enforcement of prescriptive health and safety standards, rather than improving the quality of care for all patients, has resulted in expending much of our resources on dealing with marginal providers, rather than on stimulating broad-based improvements in the quality of care delivered to all patients."
There is nothing about the Pre-Claim Review process that stimulates broad-based improvements in healthcare. How could the Pre-Claim Review Project be so far removed from the intent of the home health Conditions of Participation?
Consider that the demonstration project is resulting in difficulty meeting educational demands in Illinois and that resources have already been relocated from Florida to Illinois. Do agencies in other states have the same access to education as the agencies under pre-pay review?
According to the Medicare Pre-Claim Review Q & A:
The demonstration establishes a pre-claim review process for home health services to assist in developing improved procedures for the investigation and prosecution of Medicare fraud occurring among Home Health Agencies providing services to Medicare beneficiaries.
Nobody can deny that a small number of agencies operate without any regard to Medicare rules and only a passing acquaintance with ethics. This inconvenient acknowledgment of fraud among the ranks does not justify excessive scrutiny on 100 percent of providers. Somehow it does not seem fair to involve home care agencies in a demonstration project designed to enhance their prosecution.
And yet, agencies who fail to submit documentation for a Pre-Claim Review are put on a 100 percent review - a level of scrutiny previously reserved for agencies operating far outside of Medicare rules for an extended period.
The documentation required for a pre-claim review is reviewed for clerical errors and, dare I say, elements that cannot be established with limited documentation by reviewers who are not nurses. The reason for denial given most often per Palmetto GBA is "lack of medical necessity." We see care plans every day that are poorly crafted yet supported by excellent nursing and therapy notes. Conversely, we see plans of care worthy of a Pulitzer prize supported by nine identical visit notes at weekly intervals documenting that a skilled nurse "taught meds." Presumably these are meds ordered for the patient but who knows? Nobody asked us if it was possible to determine Medical Necessity without a complete review of the chart.
In the same vein, we see homebound status documented on visit notes that is contradictory to plans of care. In one recent chart, we found that a patient was shopping weekly. On another, a therapist documented the patient was driving, alone. Mere documentation on a plan of care that a patient meets the homebound criteria does not make it so.
Arresting litterbugs during a bank robbery
Nevertheless, reviewers are also quick to note when a signature is not dated or the date of encounter is omitted from the Face-to-Face encounter document. I agree that dates are an important step toward compliance but lack of a date is often nothing more than an oversight, not a tell-tale sign of fraudulent intent, especially since it is the physician who is responsible for the dates. If this keeps up, federal prisons will be filled with healthcare providers who forgot to date a couple of documents.
The burden to the agency is extensive. On a recent CMS conference call, many agencies reported that the PCR process was costing them $25,000.00 per month. Another agency stated it was taking them about an hour per claim. Even if these estimates are overstated, they are still far above Medicare’s estimation that it would take minimal time and expense to get pre-claim reviews submitted.
If Tom Price is confirmed as the new secretary of HHS, there may be some relief but the Georgia Congressman will oversee 13 different agencies including CMS, the CDC, the FDA, National Institutes of Health and more. While the author of most of the 60 bills to repeal the ACA over the last six years has been outspoken against the Pre-Claim Review Process, it is hard to imagine that the process will find its way to the top of his priority list upon confirmation.
So, who benefits from this circus? Is Palmetto being honest or merely saving face when they maintain the project is going well? Are our patients happier and healthier because of frantic efforts to assemble and transmit paperwork? Could resources being consumed by PCR be put to better use? What can you do?
I can only provide an answer to the last question. The first thing you should do is to contact your elected officials in Washington. After that, get your care plans and Face-to-Face documents in order because there is now an abundance of reviewers at Palmetto who are practiced at finding cause to deny. If you are in Illinois and have claims that you believe are non-affirmed due to incompetent reviewers at Palmetto, contact NAHC. Under no circumstances do we recommend ignoring the Pre-Claim Review Process merely because your state is not in the demonstration project.
I invite your comments and questions. You can write to me or to Editor Tim Rowan at this publication. We particularly want to hear from Illinois agencies (after you contact your elected officials).
©2017 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in the Haydel Consulting blog, reprinted by permission of the author. One copy may be printed for personal use; further reproduction by permission only. email@example.com