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Crushing burden comes to more states soon.

Brace yourselves: Those expecting the Home Health Pre-Claim Review demonstration to be bad may find it even worse than they feared.

The National Association for Home Care & Hospice estimates the denial, or “non-affirmation,” rate for PCR requests to be about 80 percent, says William Dombi, NAHC’s vice president for law. The Centers for Medicare & Medicaid Services has found similar rates, Dombi tells Eli. Representatives for CMS and the Medicare Administrative Contractors Palmetto GBA and CGS didn’t respond to inquiries for this story by press time.

“It is really bad here” confirms consultant Rebecca Friedman Zuber, who works with the Illinois HomeCare & Hospice Council. “Providers are angry, frustrated, discouraged and despairing,” Friedman Zuber reports.

“It is a complete mess,” Dombi says. “That is the result that we all predicted given the magnitude of the undertaking that increased the MAC’s claim review workload 40-50 times of its normal volume,” he says in NAHC’s member newsletter.

“The results so far have justified the worst fears” of the clients of attorney Bob Morgan with Much Shelist in Chicago. “The denial rates are astronomical and arbitrary,” Morgan says.

MACs “are focused on generating government savings by pushing ambiguous and unrealistic documentation requirements, which is having a severe impact on Illinois home healthcare providers caught in the wake of the demonstration project,” Morgan continues. “This is not the way to achieve better home healthcare agency outcomes.”

PCR Procedures Infuriate Providers

Problems with the PCR demo are two-fold. First, the operational details make the program incredibly burdensome. Home health agencies must collect all the information for the request — including documentation from the physician’s record — in an incredibly short timeframe. Then they are having “ongoing technical submission problems” with the system, Friedman Zuber relates.

For example: Agencies report submitted documents taking hours to go through, or being accepted and then declared illegible, NAHC says. And “endless reports of the MAC losing documents submitted electronically led to a CMS recommendation that home health agencies resort to antiquated fax submissions,” the trade group adds.

Plus: The way the system is set up, HHAs must resubmit the same documents all over again when they resubmit a request for a non-affirmed claim, Friedman Zuber points out. “The amount of time required to collect and submit the info is insane. The submission systems are unsophisticated,” she blasts. “It is a nightmare.”

HHAs are frustrated that they can’t start a PCR request, save it, and come back later, NAHC adds.

CGS just got its electronic submission system for PCR up and running, it said in an Aug. 30 message to providers. And it still can only send a PCR decision back to providers via fax or mail.

Palmetto sends the decision electronically via “greenmail” if providers submit the request via eServices. Providers that submit requests through mail, fax, or Electronic Submission of Medical Documentation (eSMD) receive decisions via snail mail, Palmetto explains in a Frequently Asked Questions document posted Aug. 30.

Documentation Requirements Impossible To Meet

While the operational details of the demo are frustrating, the clinical documentation review process is driving providers even more crazy. “The most serious PCR problems go beyond the handling of submitted documentation,” NAHC judges. “It has become clear that the MAC will reject a high proportion of pre-claim reviews on the basis that the patient is not homebound or that the care is not necessary.”

HHAs’ documentation is likely in need of a tune-up, Friedman Zuber acknowledges. “Many elements conspire to make the documentation muddy,” she says. They include “the fact that the rules have changed over and over again, the ‘gloppy-ness’ of the current EMRs they are using, survey pressures to include everything they might ever think of doing for a patient in the plan of care, clueless documentation from physicians, … and ongoing issues with documentation on OASIS not necessarily really supporting the clinical description of the patient,” Friedman Zuber lists.

F2F documentation in particular has been a moving target for both physicians and HHAs, says Morgan, who calls the new program “brutal.”

The review process for the documentation is extremely concerning, agencies report. Reviewers are frequently overlooking submitted documentation, Friedman Zuber says.

Denied requests frequently “involve patients with a clear homebound status and need for the physician-ordered care,” agencies tell NAHC. HHAs are having a hard time figuring out what the problem is, due to “the uninformative reasons given by the MAC in the rejection notice,” NAHC maintains.

For example: “Conclusory statements such as the ‘patient is not homebound’ offer no guidance to home health agencies seeking to take corrective actions,” the trade group criticizes. And HHAs are receiving such statements for patients who should be obviously qualified for the benefit, such as those who received knee replacements, NAHC points out.

There is “insufficient information on which to base a re-submission,” Friedman Zuber agrees.

Bottom line: “The reviews are … errorprone and inconsistent,” Friedman Zuber says.

When agencies do attempt a resubmission, reviewers have denied the request for reasons that were approved the first time around, Friedman Zuber adds.

Adding to the problem is that “the Customer Service Center reps have not been trained to answer questions and the providers can’t get through to someone who can,” Friedman Zuber explains. Also, patients are “upset by the letters they are receiving telling them their services aren’t covered.” Physicians are angry as well, she says.

In fairness, “I think it is clear that providers need to simplify their documentation,” Friedman Zuber allows. But that may not help, since the reviews are so unreliable.

PCR Blocks Access To Care

The high rate of PCR non-affirmations is “creating a serious ‘chilling effect’ among veteran home health agencies across the state,” NAHC reports. “Agency executives indicate that they plan to withhold the start of care until a favorable preclaim review decision is issued. It can be expected that access to care problems will escalate in the very short term unless CMS and the MAC reverse course quickly,” the trade group warns.

Medicare is pressuring HHAs not to hold off on care, however. “Providers are encouraged to submit the Request for Anticipated Payment (RAP) and allow it to process before submitting the Home Health Pre-Claim Review Submittal Request,” Palmetto says in the new FAQs. “This will allow the beneficiary record to open on the Common Working File and will assure you have all of the required documentation to submit with the request.”

The legitimate documentation problems reviewers are finding are “all things that could be worked on,” Friedman Zuber says. “But if you are providing 75 to 80 percent of your care for free, you won’t be around long enough to work on anything.

“This will be a bumpy ride for even the best home health care agencies,” Morgan warns.

Note: For a link to Palmetto’s new FAQs, go to www.palmettogba.com, click on “Jurisdiction M Home Health and Hospice” in the “Medicare Resources” box, then click on “Home Health Pre-Claim Review” in the “Top Links” box. CMS’s PCR page is at .