Understanding the Impact of Pre-Claim Review (PCR)

Summary
 
For Clinicians

• For Clinicians, there is no direct impact to you if you are on top of your notes – meaning they are clinically appropriate and completed on a timely basis.
• There are no changes to note formats per-se; complete them as they currently exist.
• The timing and quality of notes will be of increased significance for HHA’s.  Failure to submit notes on a timely basis or poor quality documentation could result in substantial financial impact for the HHA.  Please submit all evaluations within 24 hours, submit all notes for visits within five days, and all visits completed within the first 30 days within the first 30 days.
• Ensure you clearly document home-bound status, reflect short-term and long-term goals and a plan of care that is individualized and appropriate.
• Patients will also be informed of the Pre-Claim outcome, so clinicians may be asked questions about the process by patients.  Both patients and agencies may appeal a non-affirmative (denied) claim.
• Clear documentation of the reasons for a recertification, including progress toward goals and expectations for the recertification will be important and the physician must submit an explanation of their view as to when care will cease.

 
For HHAs

• Pre-claim review adds a step for HHA’s that requires a pre-submission (Pre-Claim Review “PCR”) of documentation prior to submission of the final claim to CMS. 
• The process is likely to significantly impact the behavior of HHAs; physician documentation is under increased scrutiny; the timeliness, quality and sequence of supporting notes becomes more important.
• HHA claims may be rejected as submitted for PCR.  The HHA may then submit additional documentation.  Even if a claim is rejected, as a condition of participation, HHA may are still be on the hook for providing care and cannot always immediately discharge the patient.
• As product of these changes, we are experiencing a reduction in episodes as agencies are learning the process.  They may also be more selective about whom they admit and whether they recertify patients.  It is unclear whether this is transitional or will be a longer term effect.
• If pre-claim review is not completed properly, agencies face a 25% reduction in payment amounts.

  
Detailed Explanation
 
CMS has implemented a new requirement, Pre-Claim Review (“PCR”).  This new rule has been imposed in a whirl-wind “demonstration” project.  Initial guidelines were issued on June 8th and the program was adopted and implemented less than two months later, effective August 1st, 2016 for Illinois for patients with a SOC after that date.  Illinois is the first of five states subject to the program, which will grow to include Florida, Texas, Michigan and Massachusetts. 
 
The project was explicitly announced as an initiative to reduce fraud.  The essence of the pilot is a new process that requires Home Health Agencies (HHAs) to submit documentation relating to a claim earlier than was previously required.  This allows CMS the ability to review documentation to ensure sufficient probability of payment of a claim earlier in the episode.
 
Home Health Agencies will be submitting the same documentation as has always been the case.  However, it must now be submitted within the first 30 days of the episode for the PCR. A claim which preliminarily meets the criteria established for payment of a claim will receive an “Affirmation,” meaning that CMS is likely to approve the claim.  If CMS determines that the documentation is not sufficient to meet approval criteria, the claim may receive a “Non-affirmation,” which means CMS is likely to deny the claim.  The agency may then submit additional documentation, and do so as many times as necessary.  
 
The qualifications for approval remain the same as in the past: the individual must:

• Be confined to the home;
• Be under the care of a physician;
• Be receiving services under a plan of care established and periodically reviewed by a physician;
• Be in need of skilled services;
• Had a face-to face encounter no more than 90 prior to the SOC or within 30 days of start of home care from a qualified physician.

 
For agencies, areas of particular importance will be:

• Ensuring appropriate documentation, and in particular that the physician face-to-face, certification and plan of care are all in place, integrated and complete before submission for PCR.  Many agencies may attempt to gather most of this information at the time of admission or very shortly thereafter.  Waiting for the physician documentation and signatures becomes riskier for agencies - if they deliver services but subsequently receive a Non-affirmation, they may not get paid.
• Effectively assessing whether the patient is truly home-bound, and ensuring that the physician’s plan of care integrates all aspects of care (particularly including therapy) in the documentation submitted for PCR.
• Demonstrating that the goals and treatment plan are patient specific and appropriate, that measures are identified, and that subsequent visits document progress toward goals and results.
• Ensuring inter-team communications between physician, nurse and therapist to present a thorough, integrated and consistent picture of the patient.
• Complete documentation of the reasoning behind any additions to services or changes in the Plan of Care.
• A thorough reassessment of homebound status as well continuing goals and progress, as a Physician’s estimate for the length of the continuation of care for any recertification.

 
Additional implication for HHAs include:

• The time and additional administrative burden for HHAs for PCR will impact their costs, their need for efficient and effective administrative staff, and their cash flow cycles.  It is realistic to expect that many smaller agencies with borderline efficiency will be unable to survive the additional administrative burden.
• Agencies will do admissions with limited information, and hope that they are able to assembly the relevant data quickly and efficiently.  Some are requesting that we call same day with frequencies.  Communication between members of the care team may well have increased attention as RN SOCs and therapist evaluations need to be integrated into the Physician’s Plan of Care.
• Investing in patient care, including multiple visits before a PCR affirmation is received, represents financial risk to HHAs.  How HHAs adjust their expectations and practices will be based on agencies’ case mix, relationships with MDs and other attributes.

 
The implication for clinicians include:

• There are likely to be fewer admissions, at least initially.
  • Driven in part by HHA concerns with admitting patients where home-bound status is gray.  In the past, many agencies accepted patients automatically and then would work to “fill-in” the information they needed, and would then discharge patients where home-bound status was in doubt, but usually after the fact.  Agencies are likely to take fewer admissions where homebound status is in question.
  • Driven by financial risk assumed when admitting patients where physician documentation is complete or other medical factors are not clearly understood.  Because HHA must often admit a patient with incomplete information, a non-affirmed claim would mean the HHA will be assuming substantial financial risk.
• Increased focus on the SOC and initial evaluations.  Increased expectations that evaluations are completed thoroughly and on a timely basis -- so that it can be incorporated as part of the physician’s plan of care and help the physician to certify the patient as home-bound.
•  Increased focus on clinical documentation – clear short-term and long-term goals, well defined and appropriate measures, and clear documentation of patient progress.
• More requests for follow up information or clarification of patient progress notes.

 
 
Once gathering the initial documentation has been completed, the HHA must submit the information for the Pre-Claim Review within 30 days of the start of the episode.  The CMS Medicare Administrative Contractor (“MAC” - such as Palmetto) will return a finding within 10 days of submission.  Each PCR claim also receives a UTN (“Unique Tracking Number”) which follows the claim.  A copy of the decision is also sent to the patient.
 
If the agency does not submit a claim to PCR, it may still be paid upon final submission, but the amount will be reduced by 25%.  Thus, while “voluntary”, the implementation of PCR is likely to be virtually universal.
 
Because CMS will be sending notice of its determination of Affirmation or Non-affirmation to both the agency and patient, patients are likely to ask more questions about the process and their rights and responsibilities.  Patients that receive a Non-affirmation finding are likely to want to know what and how they can proceed.  Patients have a right to assemble additional information and submit it directly to the MAC just as agencies can.  It is highly recommended that they work in concert with their HHA to do so.  Only one agency may have a valid UTN at a time, so if a patient changes agency, the case will need to be resubmitted by the new agency.
 
Conclusion
 
From a practical standpoint, the PCR process has relatively little impact on clinician’s day to day activities, perhaps with the exception of increased focus on timeliness and quality of notes.   Clinicians with strong work habits should be fine in continuing their daily work.  That said, the process will have a big impact on HHAs from a documentation timing and administrative follow-up stand-point.  Understanding and adapting to these new processes are likely to cause agencies to take additional time and admit fewer patients.  This in turn can impact the patient load and opportunity for clinicians.
 
Aptiva has positioned itself as the premier provider of quality services in the market.  We are extremely proud of the quality of the clinical care and documentation that we provide, through you, our expert clinicians.  While this may represent a short-term challenge for Aptiva and all HHAs as they adapt to new standards, we believe that in the long-run, it will help us succeed as agencies move toward quality over deeply discounted providers.  We ask all of you to stay focused on providing great care, thorough documentation, and ensuring that our patients have the best possible outcomes.  While this transition may be a difficult period, we believe that quality, high-value service will ultimately prevail, and our clinicians will enjoy an even greater level of success.