Pre-Claim Review: Delayed… For Now

Agencies in the next 4 of the 5 demonstration states are getting a temporary reprieve… implementation of pre-claim reviews has been postponed while CMS and the effected Intermediaries figure out what they are doing.  As many agencies have heard, the processes haven’t been easy, the information has been slow at release and the results have been poor.  The temporary break is only for 30 days to allow CMS and intermediaries additional time to provide education and training to agencies.


An internal memo from CMS that has been spread around amongst those in the home health industry paints a very different picture from what agencies have been saying.  The disparity in the initial analysis of this first transition is not surprising.  While we on the provider’s side anticipated a painfully flawed process and implementation, CMS is claiming statistics that would imply that the failure is the provider’s and not the intermediary’s.  While Palmetto may be just as opposed to this entire idea of pre-authorization, they certainly aren’t going to paint themselves as inept.


In their defense, they were set up to fail.  We all saw it coming, but the bureaucrats think all is well and they just need to work on training the providers a little more. Hmm…like the training provided with the probe and educate review?


Since CMS and Palmetto think these statistics are proof of their success, let’s take a look at them …make sure you are sitting down for these because you might just be overwhelmed by all the positivity.  Some of the statistics might make you wonder if, since it was the end of the quarter, some people at CMS and Palmetto were just pushing for their bonus or a nifty little team player pin for their lapel?


Submission of Pre-Claim Review Documentation:

ü 91% of all submissions were through Palmetto’s portal. (Think about this – do agencies really trust a contractor who has botched this process from the beginning to process large amounts of paper?)

ü 9 minutes to complete a submission online! (Wow put on your party hat because you have just won an efficiency award.  CMS is benchmarking itself against the 12 minutes it took at the beginning of the pre-claim review. BUT, read some more and the 9 minutes doesn’t include the 90 minutes it took the agency to gather all of the information needed for just that one submission…)


ü 99% of submissions were returned timely. (They may have actually met this one since most of the submissions were denied even when agencies had proof of a complete submission. So basically they did well on this one metric because they didn’t do their job.)

66% of all submissions are finally approved…after 8 weeks.  (Well – get ready – this couldn’t be another misleading statistic from CMS could it?  66% includes partially affirmed submissions.  If a patient requires more than one service, a partial affirmation can occur for let’s say nursing but not OT or PT. So really what is the true number?


Let’s find out why the pre-claim submissions are not being affirmed on the first submission:

ü 50.8% “Other” Documentation Errors – Great details to help agencies get on board.  Why not just call this category miscellaneous and be done with it?

ü 25% Medical Necessity Not Documented – We received a little more information; nursing and physical therapy services aren’t being documented as medically necessary.

ü  18.6% Homebound Status Not Met – The definition of homebound must be clearly defined for the patient within the submission.  This isn’t so bad (if it’s a real statistic).

ü Face-to-Face (F2F) Missing or Incomplete – Details are scant, but if you don’t have a F2F then why even submit?  Incomplete could use some more detail explanation – we have to wonder if it ties into homebound status not met and if the team of geniuses are double counting.


With the self-congratulations out of the way, you’ll be happy to know that CMS is willing to offer more extensive training for agencies in Florida. This despite their thinking that having held 12 education sessions and having answered 517 helpdesk calls regarding submissions were good statistics.  One weird item included in this support data was this: ‘19 individual calls with provider’.  We thought about this one for a while when reviewing the information provided to us and had to scratch our heads.  Did CMS have 19 individual phone calls with one (1) agency or did CMS speak with 19 individual agencies? With such ambiguous information provided, we can guarantee this stellar bit of info really helped get that team player a lapel pin and likely a large bonus.


While we may seem very critical and somewhat harsh regarding CMS’ and Palmetto’s treatment of the pre-authorizations, we need to be.  The reality is that many agencies in Illinois have been delaying patient care until a response is received – whether affirming documentation to proceed or issuing a denial for more information needed.  This isn’t helping anybody – patients, agencies, and even CMS/Palmetto.  This wonderful idea may have looked good on paper or on a whiteboard in DC and Maryland, but it certainly isn’t working very well in the real world.


A few Congressmen have taken notice.  However, due to the election this year, Congress has recessed and the bill, The Pre-Claim Undermines Seniors’ health (PUSH) Act (H.R. 6226), was not taken up.  Congressmen from Georgia, Massachusetts, and Texas were all behind the bill, which would have suspended the pre-claim review demo from hell for one year to allow CMS to climb down from their ivory towers and offer realistic, common sense solutions.


As always, we will keep you posted of changes and developments.  Our next issue will have an analysis on the potential changes coming to healthcare – specifically agencies like yours – with a new president taking the oath in January.  We also welcome your comments and ideas for different topics of coverage.