Medforce Blog

What went wrong with Pre-Claim Review?

May 22, 2017

Category: General

As of April 1, 2017, CMS halted the Pre-Claim Review (PCR) demonstration in Illinois and delayed any expansion to Florida, Texas, Massachusetts and Michigan. The original intention of the program was to develop new ways to thwart Medicare home health benefit waste, fraud and abuse.  The delay was supposed to last 30 days, but we are nearly 2 months out and there is no sign of the program getting back on track.

So what went wrong?

The symptom that got the most attention was a dangerous reduction in the ability for Home Health Agencies (HHAs) to provide timely care to patients while waiting for approvals and UTNs.  The exponential increase in paperwork and bureaucratic processes bogged down operations, impacted margins, and made the delivery of health services impossibly complicated. It makes sense that you can’t sacrifice the health of the very population you are charged with helping for the sake of paperwork, and for that reason, the program was put on hold until a better system could be developed.

But the root cause of the issue is broader than simply the amount of paperwork. The issue is that CMS focused in on only one portion of the process – the PCR submission. While they enabled esMD portals and set up the MAC processors to review the documentation, CMS did not consider the full PCR workflow and how it would impact HHA operations.  The tunnel vision on the receipt of the submission and what happens next, ignoring the upfront work, created immense strain on HHA operations that ultimately was felt by patients.

In our conversations with HHAs, we learned that it can take a biller up to 45 minutes per PCR submission, gathering the needed documentation, organizing the package, and then submitting it. With practice, HHAs are able to whittle that time in half. But 15-20 minute per submission is still a huge drain on productivity. If you have 100 submissions per week, that is a full time staff position required. At the national average salary for a Medicare biller at $15.25 per hour – 100 submissions per week will cost an agency over $500 a week in new resource allocation. This is not an easy burden for an agency to absorb.

Process definition failure

It took six months of the PCR pilot demonstration in place in Illinois before CMS had sufficient data to support putting the program on hold. While we support the decision, it came far too late. If there had been proper process tracking and business process management in place for the entire process – not just what happens post-submission – these issues would have been identified and quantified much sooner.

When an entire process can be mapped, monitored and analyzed in real time, you don’t have to fight your way through six months of utter inefficiency before change can be made. The dynamics of your operation (and the dynamics of interconnected systems) can be understood quickly and problem areas can be quickly identified and fixed.

In the simplest terms: CMS incorrectly defined the process for PCR. This resulted in the solution CMS developed to solve one challenge creating an even bigger one. In a world of interconnectedness, you can’t focus too tightly on one area of a process or you may miss the forest for the trees. And that is exactly what business process management can help you avoid doing. 

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