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Agencies Need to Be Prepared for Pre-Claim Review in FL Starting April 1st

Posted on Wednesday, March 29, 2017 8:45 PM

Although there has been major pushback from the home health care industry, the Pre-Claim Review Demonstration (PCRD) is still set to begin in Florida on April 1. The demonstration has allowed agencies to prepare for the past three years, while trying to fight for a delay or moratorium.

With that being said, Florida home health companies have expanded their efforts to stop PCRD from expanding by connecting with industry associations and legislators. U.S. Senators Marco Rubio (R-FL) and Bill Nelson (D-FL) have constantly spoken against the demonstration.

Elite Home Health is a home health agency based out of Jacksonville, Florida. The office staff at Elite Home Health was able to meet with the office staff of Nelson on the issue, and identified the Senator’s staff as “very receptive” to helping the agency against PCRD. In addition, Elite met to discuss PCRD with the office staff of Congressman John Rutherford (R-FL 4th District).

However, Elite’s President, Brandon Groover, is not expecting federal committees and agencies to sympathize.

“The House [Energy and] Commerce Committee, which oversees CMS, is under the impression that Pre-Claim is not burdensome, as CMS is presenting a rosy picture of high affirmation,” he told Home Health Care News. “I argued to the congressional staff that the affirmation rate could be deceptive, as CMS has included both partial and full affirmation.”

CMS stated that Illinois affirmation rates reached approximately 92% as of mid-January.

The concern Florida agencies have is evident – that is why they’ve tried to learn from Illinois providers that have dealt with the demonstration since August 2016.

An Illinois provider that Florida agencies should take notes from received 100% affirmation rate. The Chicago-based Simply Home Health did not start submitting pre-claims right away in August of last year. Instead, they took a backseat to the demonstration and started the process in September.

Simply Home Health’s CEO and Founder Bob Kunio is optimistic about PCRD identifying the bad guys and putting them out of business. In return, he hopes this will help to improve the reputation of the home health industry.

“We have put in so much time and effort and money getting good at this that I’m hoping we benefit by having fewer dishonest competitors,” Kunio told HHCN. “The whole purpose is to make it difficult for the cheaters to get paid.”

According to industry groups, a broad stroke to combat fraud, such as this program, causes significant burdens on do-gooders. Kunio also agrees that the program is disruptive to business, and supports some type of compromise for lifting the demonstration after a period of time. Agencies that fail to start PCRD in that time could be a red flag for fraud, he says.

PCRD specifically targets the following five states:
• Illinois
• Florida
• Texas
• Massachusetts
• Michigan

“From aggressive audits to reimbursement-related programs, Value-Based Purchasing, and now with the Pre-Claim Review Demonstration looming large on the horizon, the level of scrutiny on home care is unparalleled, and no other state has had to content with it as much as Florida,” Anthony Clarizio, President of the Home Care Association of Florida (HCAF), said in a statement at the beginning of March.

Groover does not agree that PCRD will accomplish its goal to reduce fraudulent players. In addition, he believes that other requirements are responsible for home health’s bad reputation for improper payments.

“There is a false notion that PCR is truly needed,” he told HHCN. “In fact, the erroneous face-to-face requirement is the cause of the high improper payment rate.”

Although there have been GOP promises to roll back regulations, Republicans have yet to stop PCRD.

“In a nutshell, I am not so sure that PCR will be beat this time,” Groover said.

Corridor offers a variety of services to help you navigate through the CMS requirements – including:
• Readiness Assessment
• Outsourced Services
• Documentation Review

Call Corridor today for help with Pre-Claim Review. 1-866-263-3795

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