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PGBA reviewers are still citing non-existent regulations when they do not affirm some pre-claim requests.

PGBA reviewers frequently fail to place mandatory phone calls to home health agencies to discuss non-affirmed pre-claim requests.

PGBA supervisors, when challenged on this telephone failure, swear that these calls were actually made.

Appeals for guidance to the head of the CMS Center for Program Integrity, who will be replaced on January 20, go unanswered. Apparently Dr. Shantanu Agrawal, M.D., Deputy Administrator and Director of the CPI, is using accumulated leave time, enough to carry him through the last day of the Obama administration.

A discrepancy exists regarding the number of Illinois agencies that have yet to submit their first pre-claim request. PGBA says it is "a handful." CMS reports between 200 and 300.

In a December 15 conference call, representatives from NAHC and the Illinois HomeCare & Hospice Council reported on these and other signs of progress and setbacks, and offered predictions for post-January 20 changes.

The most disturbing revelation is that PGBA reviewers are under such extreme pressure to quickly resolve cases, they appear to have resorted to speed-reading submitted documents. Several providers cited instances where they received a non-affirmation for a missing document. Over and over again, during the follow-up phone call, they had to tell the reviewer, "Please look again," and heard in response "Oops, you're right. There it is."

All medical leaves canceled?
Almost as disturbing is the way PGBA reviewers tend to make up rules on the spot when searching for reasons to dis-affirm requests. More than one provider mentioned that they were told by a PGBA reviewer that their request was non-affirmed because "it took too long for the doctor to sign the documents."

"Wait a minute," NAHC's Bill Dombi interrupted. "The federal rule only says the signature date has to precede the final claim date. There is no CMS language that says anything about two weeks or two months." Doctors, everyone agreed, are allowed to go on vacation.

Just call me!
That is only if those required phone calls actually happen. Many providers on the call strongly asserted that they absolutely do not receive non-affirmation explanation calls from PGBA. In its defense, PGBA has reminded provider agencies that they ask for their one contact person when they call. If that person is not available, they move on to the next call. Providers on the call generally pooh-poohed that excuse. "Our point person is always in the office, always available," many of them insisted.

On the good news side, PGBA is reporting, and the Illinois Council confirms, that the pre-claim affirmation rate has climbed to an average 87 percent. Only about 5 percent of these were partial affirmations, a significant improvement over the early days of August and September. (See "CMS Continues to Assert Pre-Claim is Going Well," HCTR 11/9/16).

NAHC has put off filing its planned lawsuit to stop PCR, instead electing to push CMS to change the regulation to excuse high performing agencies from the pre-claim requirement. "They have proven they are doing things right, some of them at 100%, so why should they have to continue to prove themselves," asked NAHC's Bill Dombi.

Reviewers forget they are not nurses
Everyone on the conference call was alarmed and disgusted to hear reports of non-affirmations with the reason, "aide services were not reasonable and necessary," or "I disagree with the doctor's wound care treatment plan." Dombi urged providers to document every such instance and help him bring them to CMS's attention. "These people are acting outside their authority," Dombi told them.

Far outside their authority
Some providers were furious about non-affirmations of second consecutive episodes. One provider reported getting a denial over the Face-to-Face document, a document that had been approved for the first episode. "They simply can't do that," Dombi asserted. "There is no such rule that allows this. I want you to send me the name of the reviewers that are doing this so I can report them to CMS."

PGBA is not the only party acting outside its authority. CMS itself has not been playing fair, Illinois providers reported. At first, they declared a provision for agencies situated near state borders. An Illinois agency with patients living in Iowa or Wisconsin or other border states did not have to submit pre-claim requests for those patients' episodes. Suddenly, on November 17, a policy statement came out that said they not only have to start submitting PCRs for out-of-state patients going forward but that the policy is retroactive to August 3. Dombi said he intends to fight this decision.

What about Price?
HHS Secretary-nominee Tom Price, a physician and Congressman, has been the leading opponent of PCR in the U.S. House of Representatives. Dombi's expectation is that the Senate will take up his nomination as soon as possible after Inauguration Day. Once in office, Price may take action to stop PCR right away, or he may take the time to meet with CMS personnel first. Only time will tell but there is good reason to be optimistic.

Apparently, Representative Price's opinion of PCR is even more negative than that of Florida's senators, Republican Marco Rubio and Democrat Bill Nelson, who wrote to CMS asking them to delay PCR in Florida for an additional year.

BREAKING NEWS UPDATE: As this issue was going to press, CMS thumbed its nose at Rubio and Nelson with the following announcement:

Notice for Expansion of the Pre-Claim Review Demonstration for Home Health Services to Florida

CMS will expand the Pre-Claim Review Demonstration for Home Health Services to Florida for services that begin on or after April 1, 2017.  CMS and the Medicare Administrative Contractors have provided education to impacted providers on how to submit pre-claim review requests, documentation requirements, and common reasons for non-affirmation decisions.  The Medicare Administrative Contractors will continue to conduct outreach in Florida.  

Can PGBA handle it?
According to CMS data, there are 755 certified home health agencies in Illinois. As mentioned above, PGBA reviewers are already resorting to skimming documents stacks in an effort to keep up with the workload. 

According to CMS data, there are 1,120 certified home health agencies in Florida, bringing the total workload to 250% of what it is now. The reader is invited to draw his or her own conclusions.

Bottom line
What does PCR cost? CMS promised early last summer that the impact on agency time and resources would be somewhere between minimal and insignificant. According to the Illinois experience, PCR requires at least one additional FTE for small agencies and two to three for agencies with a census of 300 or more. "Plus lots of overtime and weekend work," one caller added. About $25,000 per month for a 300-patient agency was a general consensus.

©2016 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan's Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com