Pre-Claim Reviews: Curse or Cure?

Pre-claim reviews (PCR) have caused quite a panic in the home care industry recently. QIRT consultants have been hearing terms such as “a big mess, chaos, etc.” used to describe this new process. PCR is, indeed, a change in the way agencies should be looking at the documentation showing actual beneficiary eligibility and unique care provided. The rules have not changed. However, the way the industry approaches these requirements must change if agencies want to survive in the PCR world.

So: is PCR a curse or a cure for our industry?

The curse of PCR can be measured in multiple ways. There is a large number of industry complaints about the “mess” agencies find themselves in since the onset of PCR. Added to this complaint are the number of delayed affirmations and complete non-affirmations, multiple inconsistent directions from the Medicare Administrative Contractor (MAC), …the list goes on.

But what if the MACs are right? What if it is the industry itself that has actually caused the curse?

As consultants, QIRT staff members have the unique opportunity of reviewing home care documentation from hundreds of agencies across our great nation. Unfortunately, many home care agencies actually create their own problems at times, ultimately leading to their own demise. With an increase in the number of fraud and abuse cases identified, one must wonder if the industry is being subjected to unfair reviews or if, in reality, PCRs are proving to be a wake-up call to enforce a predetermined, long-established process.

In completing reviews on records that have been subpoenaed by state and federal governments, I have found there is a noteworthy disconnect. This disconnect exists between CMS’s rules in determining beneficiary eligibility and the unwritten, self-imposed (or occasionally self-created) rules that many agencies actually follow. Although most agencies strive for compliance with CMS rules, old and hazardous habits are cause for alarm in the industry.

It is interesting to note that during FY 2013, 17.3% of all payments made to home health care were considered improper. These improper payments cost the Medicare program $3 billion. In FY 2014, the number of improper payments increased to 51.4%, carrying a $9 billion cost to Medicare. The largest percentage of the totals in each of these years was a direct result of the fact that documentation submitted for review did not support the claim. The documentation we are speaking of in this case is that related to the physician’s face-to-face and that of the clinician’s provision of care to frail, elderly, and vulnerable patients.

As the MACs review the records agencies submit seeking provisional affirmation, they are uncovering alarming findings. Findings include, but are not limited to:

  • G-codes are misrepresented (or simply not understood) by the agency.
  • Physician information supplied for face-to-face is inadequate and inconsistent.
  • Documentation by clinicians is woefully inadequate.

For years agencies have been told that documentation is the key to success. Documentation in the clinical record that clearly supports the use of the Medicare benefit as it was intended is missing. We need a documentation revolution. The lack of agency training and understanding of the home care benefit and the requirements for documentation with a high degree of specificity has taken its toll.

As experts in the industry, it is QIRT’s opinion that PCR may just be the reveille needed. These reviews may be the cure to what is actually causing the harm to our industry.

In the recent past, CMS has used other techniques to initiate corrective action within our industry with little (or not enough) success. PCR may be the answer. Medicare’s decision to stop the game of pay-and-chase has begun in Illinois and is headed to four more states very soon. Reviewing documentation related to eligibility and services to be rendered will provide CMS with data in real time, prior to paying claims. PCR promises to provide the Medicare program with a significant amount of data.

The homecare industry has never liked change. But change is here, and change can be our friend. If agencies heed the warnings from the issues being identified today, they may encounter the necessary cure and experience a better tomorrow.

Arlene Maxim

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