*InBoxing is one of our formats of written content that is largely driven by the email exchange between two or more experts in a particular field of the Healthcare Continuum.
At the beginning of June, the Centers for Medicare & Medicaid Services (CMS) reintroduced the suspended Pre-Claim Review Demonstration. For a traditional article on this topic, read this piece by Robert Holly of Home Health Care News. But to gain my own full understanding of what this PCRD resurrection could mean for the Home Health industry, I emailed my friend and Home Health heavyweight Aaron Little of BKD. This piece is essentially an unedited account of our email exchange.
Tripp Matthews (me): CMS has resurrected Pre-Claim Review. Why have they done this and what does this mean for Home Health?
Aaron Little (AL): I think there are several reasons why CMS is resurrecting the PCR demonstration. It was initially to be a three-year demonstration project and the “pause” on April 1, 2017, was less than a year into the very costly, highly criticized demonstration. The pause was never stated as a discontinuation, but rather an actual pause in the demonstration project until such time CMS could “consider a number of changes to improve the PCR demonstration.”
I think a very relevant reason CMS has resurrected the PCR demonstration (which is now called Review Choice Demonstration [RCD]) is because the Medicare improper payment rate as computed by the Comprehensive Error Rate Testing (CERT) contractor remains extremely high. In 2017, the CERT estimated the improper payment rate at 32.3%, or $6.1 billion dollars. While this was slightly down from the prior year, it’s still so high it keeps the home health program at the unwanted forefront of concerns for compliance risks. And, when it’s remained so high for the past several years, it’s no surprise it would be an easy target for CMS. Consider the following CERT home health improper payment rate trend:
- 32.3%/$6.1 billion in 2017
- 42.0%/$7.7 billion in 2016
- 59.0%/$10.1 billion in 2015 (the peak)
While the above trending information has been publicly available for quite some time, I think another very relevant reason for “why now” is the Government Accountability Office (GAO) Report to the Committee on Finance, U.S. Senate dated April 2018, which estimated that during the PCR demonstration’s short life it saved an estimated $104 million to the Medicare program. In this report, the GAO explicitly stated a recommendation that CMS resume the paused demonstration.
In brief, what I think this means for home health agencies—particularly those in the proposed demonstration states of Illinois, Florida, Texas, Ohio, and North Carolina—is that they need to prepare for the probability of the demonstration being reinstated. Specifically, they should examine their documentation practices to ensure the basics are being well documented in a timely and efficient manner, including: homebound status, skilled need, and physician certifications, including face-to-face encounters.
ME: This element of this is particularly notable to me: “While the above trending information has been publicly available for quite some time, I think another very relevant reason for “why now” is the Government Accountability Office (GAO) Report to the Committee on Finance, U.S. Senate dated April 2018, which estimated that during the PCR demonstration’s short life it saved an estimated $104 million to the Medicare program. In this report, the GAO explicitly stated a recommendation that CMS resume the paused demonstration.”
What that says to me is that despite the controversy of the original Demonstration – it was actually working (at least somewhat) from the perspective of the GAO. Which is somewhat damning to the Home Health industry in this regard: When CMS implemented this initially, it was basically because of the amount of “improper” money being made by HHA’s was too high due to fraud, abuse, other nefarious practices and probably some non-nefarious inaccuracy. The Home Health industry said, NO! We’re not doing that any longer! But yet, if the brief initial run of PCR led to significant money savings – doesn’t that mean that CMS/the GAO/etc. were right, or at least correct, in instituting the program in principle?
AL: I think you’re right that from the perspective of the GAO, the home health demonstration project was working to reduce expenditures, but it’s really hard to truly gauge the accuracy of that perspective. The information presented in the GAO’s report shows reduced expenditures up until March 2017, which is when the home health demonstration was paused. But, what happened to expenditures in the months of March 2017 and after? Did expenditures bounce back up to typical historical levels, or possibly higher? If so, then that would suggest that agencies who struggled with the PCR demonstration were then able to rebound and resume historical billing practices.
ME: Changing gears from the “Why” to the “How” – why was the initial implementation/demonstration of PCR such a disaster from an administrative and organizational perspective?
AL: I think to describe the initial implementation as a disaster is unfair to those organizations who were able to adapt successfully to the PCR process, because there were such agencies. But, those that adapted well to PCR still were impacted financially because of the administrative burden PCR imposed. But, for every successful agency there was another agency that really struggled for various reasons. Some didn’t have good processes prior to PCR and then PCR exacerbated those problems, such as ineffective streamlining of order management and FTF documentation processes. In order for PCR or the new proposed demonstration(RCD) project to work, there has to be effective order management and FTF documentation processes.
ME: I appreciate you taking the time to do this, and I’ll leave you alone after this last question: What, in your educated and experienced opinion, can be done to streamline the PCR demonstration so as not to hamstring the Pilot states and agencies with as much unnecessary red-tape as is possible?
AL: You’re not bothering me! (at least not that bad ??) As I said in my last email, it’s critical that agencies assess their processes. Are they timely and effectively completing a comprehensive assessment and plan of care development? Are they effective and efficient—and compliant!!—in their order management and FTF documentation processes? Are they able to reduce the number of days these processes require to allow for the extra time required by the proposed demonstration project? If the answer to these questions is ‘no’ then the agency has some real work to do to prepare.
To learn more about this “new” issue, you can register for Curaport’s webinar on this topic, presented by Aaron Little himself, on September 13th. Click here to register.
About the Contributing Author: