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Pre-Claim Challenges Home Health & Physician Relationships

Posted on Thursday, October 20, 2016 12:38 PM

Illinois continues to deal with continuous challenges due to the Medicare Pre-Claim Review (PCR) demonstration. The important issue is making sure home health can work together with physicians.

An early concern for agencies was the requirement of having a physician signature on the home health plan of care. The program rollout has been a disaster in Illinois, and due to the pressure from Congressional lawmakers, CMS delayed the plan to additional states.

It appeared early on that CMS was not doing a thorough job of educating physicians about the pre-claim review, Cheryl Meyer, director of clinical excellence at Advocate Health, said Tuesday at the Home-Based Care: Financial Leadership Forum in Chicago.

Physician associations began calling Advocate during the summer asking what the pre-claim review entailed, suggesting that they were not getting that information from CMS, Meyer said.

Advocate also has stopped accepting home health referrals until all the documentation is furnished up front, Meyer said. This is a change from the prior approach, which generally was to take accept the patient and then chase the paperwork.

If a patient’s care is delayed due to the lack of documentation, that is entered into a patient safety database, she said. Collecting data about the impacts of pre-claim on access to care is one important step that providers should be taking, so that CMS and lawmakers can have hard numbers showing the negative impacts of the program.

It was a point strongly echoed by Joy Cameron, VNAA vice president of policy and innovation. “I don’t think they’re doing this purposefully,” Cameron said of physicians not hitting all the necessary marks related to documentation. “It’s extremely confusing to have a home health agency say, ‘When you’re describing homebound status, can you make sure to use the following phrasing, because this is what our MAC really likes.’ I think physicians might have their hackles raised a little bit, because they say, ‘I said they’re homebound.’ Yes, but the MAC is looking for specific language.”

A more long-term effort at Advocate involves working with the hospital to put in tools and processes with the goal of getting more consistently high-quality documentation for home health and other post-acute providers, Meyer said.

Meyer said she is somewhat regretful that it was not executed earlier, and says that a certain home health mindset about physicians may need to change.

“It’s a culture that we have with medical documentation, that we always try to make things easy for physicians, [who] say they’re busy,” Meyer said.

Neither Meyer nor Cameron supports PCR—Cameron went so far as to call it “an evil that needs to be stamped out.” However, while it is ongoing, agencies may be well-advised to not get too defensive, Meyer suggested.

“The very first [pre-claim] I submitted was not affirmed,” she said. “I’m looking at the non-affirmed reason and [the MAC said] it doesn’t appear this patient is homebound. I could see where they could say that, but it’s then going back to the physician, asking them to do better documentation, and then it went through. That’s that quality assurance process … you have to look at it with a very critical eye, not defend it.”

“You just can’t give up,” Meyer said.

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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