FutureFocus August 8, 2018

Lisa Remington

In this week’s FutureFocus, palliative care and hospice are in the spotlight. A bill called the Palliative Care & Hospice Education Training Act passed the House at the end of July. It establishes greater palliative care workforce training programs for doctors, nurses and other health professionals. In another story, the OIG is taking a closer look at hospice and finding vulnerabilities. We provide the report that has some eye-opening findings. 

Lisa Remington, President, Remington Health Strategy Group

By: Ronald M. Schwartz, Contributing Writer, The Remington Report

What’s in a name? Evidently a lot when it comes to CMS’ “Pre-Claim Review Demonstration” for home health services. So shortly after the Centers for Medicare & Medicaid drafted a proposed revision of the PCRD for the May 31 Federal Register, the agency changed the name to a more benign “the Review Choice Demonstration for Home Health Services.”

The RCD project, according to CMS in a Q&A Update guidance, will “incorporate more flexibility and choice for providers, as well as risk-based changes to reward providers who show compliance with Medicare home health policies.”

"The proposed RCD project will give providers in the demonstration states an initial choice of three options--pre-claim review, post-payment review, or minimal post-payment review with a 25% payment reduction for all home health services."

But in the 60-day comment period that ended July 30, among the 468 comments filed: “We strongly believe that PCRD has served its purpose that it does not need to be reinstated in the form of RCD,” William A. Dombi, National Association for Home Care & Hospice (NAHC) president, wrote CMS. As for PCRD, the agency April 1, 2017 “paused” but never restarted the project in the first of five states, Illinois, following broad opposition to the often-needless paperwork burden. That project’s emphasis, like today’s proposed replacement, was in preventing fraud in Medicare home health services.

Dombi noted that in the time PCRD was in operation in Illinois, August 3, 2016 through March 31, 2017, “the acceptance rate of submissions rose from 40% to over 90%. In fact, the affirmation rate effectively translates to a nearly 100% acceptance as resubmissions that result in affirmations are counted as separate submissions.”

The PCRD project “established that the central issue is not fraud or claims for non-covered care,” Dombi added. “Instead, the near perfect affirmation rate is due to improved documentation practices within home health agencies and improved reviews by Medicare contractors. As such, PCRD has established documentation errors and deficiencies as the root cause of an increased claims error rate. CMS officials had expected that to be the finding. The next generation PCRD should be built on these lessons learned, not simply restarting PCRD with the minor tweaks and labeling changes that is RCD.”

(The proposed RCD project will give providers in the demonstration states an initial choice of three options--pre-claim review, post-payment review, or minimal post-payment review with a 25% payment reduction for all home health services.)

CMS “Seems Determined to Move Forward”

Joy Cameron, ElevatingHome vice president of Policy and Innovation and Visiting Nurse Associations of America, noted: “Within the RCD demonstration there are the provisions for a ‘Gold Standard,’ for providers who achieve a 90% or greater affirmation rate during initial review. While we believe that RCD is a step in the right direction, we request that CMS work with us to help ensure that RCD is not implemented before policies, guidance, and training have been fully developed and implemented.” [According to the CMS proposal: Once an HHA reaches the target pre-claim review affirmation or post-payment review claim approval rate, it may choose to be relieved from claim reviews, except for a spot check of their claims to ensure continued compliance.]

“Regardless of the lack of success in curbing waste, fraud and abuse in the Pre-Claim Review Demonstration, CMS seems to be determined to move forward with minor modifications in the Review Choice Demonstration,” Cameron wrote. “ElevatingHOME and VNAA continue to stand ready to assist in this manner and have volunteered guardrails to both CMS and the HHS Office of Inspector General.”

Nevertheless, Cameron concludes: “This demonstration sadly seems to be in complete opposition to the Administration’s claim of wanting to place patients over paperwork.”

Given that the RCD seems inevitable, ElevatingHome/VNAA and The Partnership for Quality Home Healthcare, have raised a number of questions over the project’s design and whether CMS can provide the necessary corrections and provider guidance before the October 1 deadline (or, in CMS words “no earlier” than October 1. Five states are the initial sites; CMS will stagger implementation, beginning with Illinois, then expanding to Ohio and North Carolina, and later to Texas and Florida. The demo is for five years.)

The Partnership, a national coalition of home healthcare providers, among other issues zeroed in on criteria for the “Gold Standard,” with questions needing answers such as:

“Once an HHA achieves a 90% affirmation rate from a minimum of 10 claims, how will providers be notified of their qualification for the Gold Standard Exemption?

“Will providers achieving a 90% affirmation rate continue to submit pre- or post-claim review until they are formally notified of qualifying for Gold Standard Exemption? What is the time period to be between the time a provider achieves a 90% affirmation rate and notification by CMS to the provider of the qualification for exemption?”

CMS promises in the Q&A Update, click here, to release “additional information…in the coming months.”