We’d Like to Avoid PCR, Like the Plague, However…

We’re all hoping, of course, that it will not happen, but it looks like CMS has the intention of spreading the ‘plague’ called Pre-Claim Review (PCR) into other states, including Florida (slated for April 1) and Texas (date to be determined). This plague got its start in Illinois. Illinois providers, through a painful process of trial and error, have mostly survived by changing processes and improving their immunity.

It is time to ‘vaccinate’ against the new plague with training of all staff regarding the PCR process and getting back to the basics of Medicare Home Health eligibility and payment. Now, more than ever, nurses and other clinicians need to perfect their assessment skills and adequately complete the OASIS.  It is imperative that the staff responsible for obtaining face-to-face documentation and recertification statements, etc are up-to-date on the expectations. CMS will be sending letters out to physicians regarding the process, so you will probably need to provide further education as the education provided by CMS will have a cooling effect.

As CMS has explained, the PCR process is voluntary, however it is important to know that if you decide to bypass the PCR process your documentation will still be reviewed, and even if it is adequate, your episode payment will be reduced by 25%.  You cannot appeal this decision, nor may you pass on the cost to the patient!

If you participate in the PCR, you will receive a decision of ‘affirmed,’ ‘partially affirmed,’ or ‘non-affirmed.’ In the beginning, your charts will likely be either partially affirmed or non-affirmed. PalmettoGBA (or other MAC, depending on the agency’s location) will provide a complete list of the missing or inadequate documentation, so that the agency can mitigate the errors.

Download the Pre-Claim Review guide located on the CMS website. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Pre-Claim-Review-Initiatives/Overview.html

Don’t let your agency be unprepared for Pre-Claim Review.  This process is NOT just for billing people. You will need someone (or more than one someone) on your staff responsible for gathering the documentation and reviewing it for sufficiency, then responding to the MAC reviewer. That person needs to be the one who knows the home health rules and documentation standards the best.

So, maybe we avoid the plague of PCR…there are lesser diseases out there that can damage your agency, like ZPIC audits and Probe and Educate audits. Any improvements that can be made in your processes and documentation can improve your immunity.

Need assistance in the educational aspects or process development? Selman-Holman & Associates, LLC is the expertise you need to work through this plague and build your immunity. Contact us at 214.550.1477 or Diane@selmanholman.com or Cathy@selmanholman.com.

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