After the Announcement to Pause Pre-Claim in IL and Delay in FL, Providers are Looking for Answers

Posted on Wednesday, April 5, 2017 2:11 PM

When the announcement was released that the Pre-Claim Review Demonstration (PCRD or PCR) would be put on hold in Illinois and delayed in Florida, the home health industry gained a sense of relief.

For agencies, the question is what’s next? While the program undergoes review, some home health care agencies in Illinois and Florida are seeking answers to some unresolved questions.

With a pause of 30 days, providers are wondering what changes are to come.

According to those who attending the March 28 meeting with Verma and CMS officials, CMS could make the demonstration optional. While others rumored that changes would include targeting specific diagnosis codes and attempting fixes to other areas.

“I am cautiously optimistic as we have not received clarity what the pre-claim replacement will be,” Brandon Groover, President of Jacksonville, Florida-based home health care provider Elite Home Health, told HHCN. “I have seen some reports that predict CMS will return to the drawing board to make the Pre-Claim process less burdensome. Another suggestion being floated around is that pre-claim may become voluntary. The upside would be that agencies can avoid being targeted for Medicare audits. If it makes sense, Elite would likely participate.”

Since the announcement of the pause in Illinois, CMS has not provided any specific details or changes to the program yet.

“CMS is considering a number of structural improvements in response to feedback received on the demonstration to date,” CMS officials told HHCN via email.

According to those who attended the meeting, it is likely that CMS will announce changes within the next few weeks.

With the current pause in Illinois, some home health agencies that haven’t been participating in the demonstration are now seeking guidance on how to move forward in the interim.

“It has been very fast-moving,” Sara Ratcliffe, executive director of the Illinois Home Care Council, told HHCN. “Both sides [MACs and providers] are wondering what the pause means.”

Providers don’t have to submit pre-claims for episodes of care in Illinois, but at least one agency has already run into confusion over the status of claims, a source told HHCN.

According to David Curtis, President of Illinois-based Residential Home Health, MAC Palmetto has also been slow in providing direction over the last few days. After submitting claims following the PCR pause, Curtis was told two claims went into a “suspended billing status,” while Palmetto official stated they weren’t sure of that meaning once Curtis inquired.

Curtis is worried that Residential’s claims could fall into a “billing black hole” while Illinois waits for guidance.

Even though there are uncertainties right now, providers are celebrating the pause, including Kindred Healthcare (NYSE: KND).

“Kindred fully supports appropriate program integrity efforts that address fraud and improper payments while preserving access and high-quality outcomes,” Benjamin A. Breier, President and CEO of Kindred, said in a statement. “We are committed to working with CMS and Congressional leaders to develop and initiative that effectively targets improper payments without impeding patient access.”

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