The federal government's plan to bring back a payment review project for home healthcare agencies "will increase costs to patients, providers, and taxpayers," "effectively overrides the judgment of the clinician," and "will only hurt and not help the elderly."
That's a small but representative sample of the 286 public comments the Centers for Medicare and Medicaid Services (CMS) received about its Review Choice Demonstration for Home Health Services (formerly the Pre-Claim Review Demonstration for Home Health Services). The opposition is no surprise considering the original project's rollout in Illinois resulted in major problems, reported delays in access to care, and even some home healthcare providers going out of business.
The initial issues in Illinois were severe enough that CMS put the rollout on hold in April 2017. In its plan to relaunch the program, CMS says it has made changes "to incorporate more flexibility and choice for providers." It has also changed which states it is including in the review program. The original pilot states were Illinois, Florida, Texas, Michigan, and Massachusetts. Under the new plan, Illinois will still go first, but North Carolina and Ohio will replace Michigan and Massachusetts. CMS has not explained why it is changing pilot states, although one thing the new batch of states has in common is that all five share the same Medicare Administrative Contractor: Palmetto GBA.
If a provider is not in one of those states, it does not mean the provider is off the hook. CMS is banking on seeing considerable savings and increased compliance through this program. If those expected savings are realized in the five states, the federal government will want to replicate them nationally.
Consistent with the program's new name, Medicare home healthcare providers will be able to choose which type of scrutiny they prefer.
The first option-and the option providers are most likely to select-is prepayment review. The provider would submit all documentation supporting the previously filed Medicare claims to Palmetto GBA or another contractor on the front end, before any payment is received. If a provider's documentation meets all of the compliance review requirements, the claims will be paid. If any compliance requirements are not met, the claims will be denied. A provider must reach a certain success or "affirmation" rate before the provider can be removed from the program.
In Illinois, where the preclaims review program was piloted, many home healthcare providers reached the required affirmation rate.
CMS is calling this the "Gold Standard" exemption. "We believe that the Gold Standard is consistent with CMS's 'Patients Over Paperwork' mission and will help alleviate administrative burdens for all stakeholders without compromising program integrity," a national coalition of home healthcare providers called the Partnership for Quality Home Healthcare wrote in a public comment.
But the coalition also asked for clarity on how quickly providers would qualify, what their options would be to appeal, and how long the exemptions would last. Those questions point to another issue: There is still a lot of uncertainty as to how the Review Choice Demonstration will play out. These logistical concerns led to the Partnership calling for a delayed rollout, additional discussions and transparency moving forward.
The second option for providers is to subject all claims through postpayment review. If a provider chooses this option, their revenue cycle will not be disrupted. However, this puts a provider at a significant risk of large paybacks and time-consuming appeals. It also does not reduce the administrative burden because the provider will still have to submit all supporting document for every billed claim.
The third option-or if a provider does not choose either of the above options-is that the provider incurs a 25% reduction in their payments. This option would not, however, immunize a provider's claims from review.
"Instituting 100% preclaim or postpayment review, or minimal review with a 25% payment reduction, will force home health agencies to reduce wages or eliminate positions altogether to compensate for the increase in administrative and financial costs," physical therapist Ruth Haefner from Michigan wrote to CMS.
That was a common refrain in the public comments: The administrative burdens of this approach will make it unworkable. Some home healthcare agencies have said it can take over an hour to submit the documentation for one claim-and there can be hundreds to submit each day. But CMS has not increased reimbursement rates to pay for the additional staff or outside vendors that providers would need to comply.
The lack of any targeting is at the heart of this issue for home healthcare agencies. Prepayment and postpayment review are not new concepts and can in fact be useful tools when applied with surgical precision. But the Review Choice Demonstration takes a shotgun approach, reviewing every claim submitted by every home healthcare agency in the five rollout states. Even the "Gold Standard" exemption would take significant time and resources to achieve and complying with that mandate would be difficult for all the involved parties, including the government contractors facing an exponential increase in documentation.
The timing of this rollout is also problematic because of another, even more significant payment change CMS has announced. It is called the Patient Driven Groupings Model, and it is a once-in-a-generation shift in the way that home healthcare services would be provided and ultimately reimbursed by Medicare. Among other things, the new proposed rule would alter payments based on patients' acuity and cut the time in half that providers have to certify that their patients are eligible for Medicare. CMS is aiming to rollout the changes in 2020.
If that rule and the Review Choice Demonstration play out as currently planned, it would mean providers who are able to comply with the administrative burdens of one-which is no easy task-would quickly have to adjust to a different payment model while simultaneously subjecting the claims to review. The compliance requirements in the Patient Driven Groupings Model are not tweaks around the edges-they are seismic shifts. These sizable changes often require feedback or clarification after rollout as providers work to implement the new model. The introduction of the Patient Driven Groupings Model may ultimately be the reason that the Review Choice Demonstration is delayed or permanently shelved.
However, home healthcare agencies in Illinois, Ohio, North Carolina, Florida, and Texas should begin planning for compliance with the Review Choice Demonstration. The 60-day public comment period for the project closed recently, and providers should continue monitoring CMS to see if it makes adjustments based on those comments. State and national home healthcare associations can be excellent resources to help track the changes and prepare for the rollout.