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Lessons to be Learned from Illinois Agencies Regarding Pre-Claim Review

Posted on Tuesday, March 7, 2017 8:28 PM

Although there has been extreme criticism surrounding the Pre-Claim Review Demonstration (PCRD), the program is still set to go into effect for Florida in April. Due to the rough start for Illinois, many home health providers are experiencing a huge learning curve to get pre-claim submissions affirmed.

The home health industry has faced a widespread panic since the program requires home health care agencies to submit care documentation to Medicare Administrative Contractors (MACs) much earlier in the process.

Therefore, Illinois agencies have provided the industry with some feedback to make the transition a little less overwhelming.

1. Provide consistent and specific documentation
“We learned we had to get a good understanding of what the reviewers were expecting to see in the documentation,” Rachel Hecox, Director of Nursing at Western Illinois Home Health Care, told HHCN. “We relied heavily on the calls from Palmetto to give us specific directions on the submitted docs. We also relied on the weekly calls with the National Association for Home Care & Hospice (NAHC) and the Illinois Homecare and Hospice Council to give us guidance to handle these issues, and also really just to commiserate with other home health colleagues.”

“There is a lot of room for interpretation, as far as what they are requesting in medical records,” Hecox said. “It was through trial and error, a lot of back and forth, to drill down to what was expected.”

2. Get management on board
“A lesson that stood out for me the most is that the agency has to have strong leadership and be able to manage change,” Marvin Javellana, CEO and Founder of Better Care Home Health Inc., a home health care agency based in Des Plaines, Illinois, told HHCN. “I believe that most owner/operators have the clinical and regulatory knowledge that is required by PCR. What most struggle with, including us, is the ability to get everyone in the same page on these changes for effective collaboration and implementation of PCR.”

“Change has now become a constant in healthcare at a more frequent rate,” Javellana said. “My advice to the agencies that are in the PCR states is for the management team to brush up on their Change Management skills. This will be a good place to start in order to lessen the anxiety of PCR.”

3. Educate physicians
According to Katharine Eastvold, Director of Regulatory and Government Affairs at the Illinois HomeCare and Hospice Council, “Educating the physicians is one key that would apply across the board.” “Agencies need to develop that relationship so that the physicians not only understand the process, but also that it’s imposed on the entire state. Many have been understanding,” she told HHCN.

4. Have the right staffing structure
“There was a lot of variety among the agencies,” Eastvold said. While many agencies struggled to comply with a steep PCRD learning curve, not all critiques of the program are negative. For instance, any bad apples unable to comply with the program could shut down and open up recruitment opportunities for legitimate providers, says Javellana.

“Although PCR is challenging at first, it also brought to light the agencies that were not legitimately doing business,” he told HHCN. “Most of them went out of business or [are] in the process of going out of business. This means more pools of potentially good clinicians are available in the market. It will drive the very high per visit rate in Chicagoland down for per diem clinicians (compared to other states like California, which has a higher cost of living).”

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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