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Agencies Voice Their Opinions Against CMS’ ‘Misleading’ Data on Illinois Pre-Claim

Posted on Thursday, October 13, 2016 2:53 PM

Providers in Illinois continue to report numerous problems with the non-affirmation rates for claims submitted under the Pre-Claim Review Demonstration. However, the Centers for Medicare & Medicaid Services (CMS) recently released data that illustrates the program as proceeding smoothly.

However, people are labeling the data as entirely “misleading.” The data was released shortly after CMS delayed implementing the demonstration in four other states—Florida, Texas, Massachusetts and Michigan—and lawmakers continue their efforts in attempting to delay the program by a year.

“The CMS data is highly misleading,” a review of the data from the National Association for Home Care & Hospice (NAHC) reads. “It does not include the extensive time needed to collect the documentation for submission, nor does it include the time is takes to review all that documentation for compliance. While CMS is correct in stating that HHAs have the responsibility to collect this documentation, its assemblage, review and submission is a new requirement under the demonstration project.”

Reports included that submitting claims only took a few minutes. However, a Michigan-based home health care provider with a presence in Illinois, Residential Home Health, explains that it takes roughly 45 minutes to hour.

“That’s a gross misrepresentation of all the pre-work that has to happen to organize everything in the documentation,” David Curtis, president of Residential Home Health, told Home Health Care News, speaking of the CMS data. “It’s like saying it only took two minutes to sign a tax return and put a stamp on it. But how long did it take to prepare the filing?”

Furthermore, NAHC disagrees with the affirmation rate CMS noted—66%. “The rejection rate is also higher than the reported 34%,” according to NAHC. “…A ‘partial affirmation’ is a partial denial. The financial impact of partial affirmations can be significant.”

“Medicare beneficiaries cannot withstand a 34% rejection rate,” the NAHC response says. “PCR is a direct barrier to care access.”

“Even if the numbers are true, 34% rejection rate is still not good,” Ratcliffe said. “That’s one-third of business being denied. That’s not sustainable. What I would hope is that they delay this.”

Overall, the CMS data release added more frustration that providers are feeling towards pre-claim.

“It’s not in touch with reality,” Curtis said. “The most frustrating thing is that I don’t see how applying this financial and operational burden, and by applying the regulations to all providers, reduces fraud. It’s diverting resources that would otherwise go to patient care. If it needs to be put off in the other four states, what’s so special about Illinois to continue this burdensome regulation and cut off patient access to home care services?”

CMS also provided data on the top four reasons for non-affirmation.

“There no consistency to non-affirmed reasons, and they give you compounded reasons,” Curtis told HHCN. “They aren’t consistent. This review process, particularly with face-to-face, is so subjective. The inter-rater reliability is not high.”

The “compounded reasons” refers to the fact that many claims have more than one reason for non-affirmation—and sometimes all four reasons are listed. As a result, the data on reasons for non-affirmation may be less than helpful to home health agencies.
Furthermore, the data is not consistent with reports that “insufficient documentation” has resulted in a 94.8% error rate, according to NAHC.

“There’s a lot of confusion out there,” Ratcliffe said of the inconsistency. “I think the Palmetto reviewers are confused and what they are saying to providers is confusing.”
However, over the eight weeks the demonstration has been underway, Curtis says the responsiveness of CMS and the Medicare Administrative Contractors (MACs) has improved. Yet, they are not perfect by any stretch.

“When questioned specifically about the language within the CMS policies as to why a certain physician encounter or signed Plan of Care does not meet the requirements, several of the reviewers are unable to reference the exact policy and have quoted responses such as ‘based on how we were trained’ or ‘that is not my understanding,’ instead of a discussion and reference about the specific written regulations within Medicare policies,” said Nate Johnson, an administrator with Health Resource Solutions, an Illinois-based nursing and therapy agency.

“The homebound rejection and the face-to-face rejection could significantly be reduced if we educate the physicians or the physicians have skin in the game,” Javellana said. “It doesn’t affect them. I feel that that’s a big factor. Why is the burden all on us at this moment?”

“Everyone is trying to be more responsive and live up to the expectations of CMS,” Curtis said. “But the challenge is that in order to get paid by Medicare, Palmetto is asking us to submit the OASIS admission visit and therapy evals with all that paperwork signed by the certifying physician. That’s absolutely a new requirement. It’s out of the regs. It’s the biggest head scratcher I’ve seen in 15 years in the industry.”

When the Pre-Claim Review Demonstration is reinforced, Corridor is here to help.

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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