Pre-Claim Review (PCR) – Be Careful What You Wish For

That was close, Florida.

Literally hours before implementation, Florida home care agencies received the news they were hoping for.  A long-awaited hold has been placed on pre-claim reviews (PCRs) in Florida and a pause has occurred in the state of Illinois. After months of laboring with a poorly prepared Palmetto in Illinois, agencies in that state can now take a deep breath and go back to original billing policies and procedures.

However, is this really a good thing? Like that old saying, “Be careful what you wish for”, this pause/hold could be an effort to take PCR in a different direction – perhaps a nationwide implementation. While the impetus behind PCR was an effort to detect fraud, it appears that discovering fraudulent activity was not accomplished. What became evident, however, is the lack of understanding many providers have regarding patient eligibility and admission/recertification processes. In particular, face-to-face requirements and medical necessity are not being met.

Many experts in the home health agree that this pause/hold could trigger an expansion of this program to states nationwide.

Documentation related to medical necessity and homebound status has been a challenge for agencies and physicians for decades. While we have only been dealing with face-to-face for six years now, it has been a struggle to gather the necessary documents indicating patients’ homebound status and need for services. CMS recognizes this.

MACs and other oversight agencies promoting PCR are lobbying CMS hard to keep it going. Agencies and a number of legislators seem to want it either re-designed in its current form or dismantled altogether. It is important that agencies take this time to re-train staff on documentation practices related to medical necessity and determining patient eligibility.

The CMS announcement indicated a 30-day pause. So, for now, we will wait.

-Arlene Maxim, RN

VP QIRT Program Development

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