By Tim Rowan, Editor and Publisher of Home Care Technology Report

Arriving at a complete understanding of the complex Illinois experience under the first Pre-Claim Review pilot and interpreting it for our readers is too large of a task at this early date. Instead, we offer nearly all of the comments we have heard — from Illinois providers, the Illinois Homecare and Hospice Council, and NAHC — without comment. Let readers come to their own conclusions. [Rowan provides a cogent review of responses that he received from the Palmetto Government Benefits Administrators (PGBA), multiple healthcare at home providers who took part and submitted claims in the state of Illinois pilot program for submitting pre-claim reviews (PCRs), among other commentators. Details about specific  problems with submissions –and also means for circumventing problems with submissions– are noted.]


PGBA came to Illinois in July, put on four trainings across the state. Then they moved on to Florida and Texas. Since then they have posted some webinars online.

Non-affirmation rate for Illinois Pre-Claim Reviews is as high as 80% in most of the state. HHAs attached to large hospital systems report a 50% denial rate. Most approvals, however, are still marked “provisional.” Neither CMS or PGBA has explained what that means.

Reviewers at PGBA provide no explanation for denials, as CMS has instructed them to do. They may say “no evidence of medical necessity” but offer no further education or detail, making it impossible for the agency to know what changes to make when they resubmit for a second review.

Many HHAs are astonished and puzzled to report that they have occasionally resubmitted after a denial, making no changes, and the second time it is affirmed. Apparently, it depends on which reviewer you get, even though the decisions are supposed to be rule-based, not subjective.

Resubmissions are supposed to require only the corrected documents. CMS says it is working on a systems upgrade but at present reviewers have no way to associate a second submission to the original, denied request. No matter how many pages are submitted, reviewers see them as one long, consolidated document. They either cannot or will not search for earlier iterations from the same episode. According to what Bill Dombi has been told, they are not even aware they are looking at a second submission or that there was a first one.

Because of this problem, PGBA reviewers are unable to comply with the CMS rule that they must not issue a second non-affirmation for a different reason that was not found to be deficient in the first submission. However, as they are unaware they are looking at a resubmission, they frequently look into the documents that were deemed acceptable the first time and find flaws in them, not knowing they are violating the rule.

Patients receive a letter every time there is a pre-claim non-affirmation. Many of them become distressed and call their HHA in a panic, asking what it means.

Originally scheduled to begin on August 1, a Monday, CMS changed its mind at the last minute. PCR documents can only be submitted for episodes beginning on or after August 3. Nevertheless, many HHAs report that they have received PCR non-affirmations for episodes that did in fact begin on or after August 3, with the denial reason, “PCR cannot be submitted for episodes that began prior to August 3.”

When PGBA specifies information needed, they often ask the same question in three different places. HHAs have learned reviewers will not search through the documents to find the answer so they have learned to submit the same exact document three times. Otherwise the reviewer will claim the question was not answered.

Contrary to established norms, PGBA requires separate documentation for every discipline. Prior to PCR, an episode could start with physical therapy only, but if the patient has a medical change in condition, perhaps takes medications wrong and becomes seriously ill, the agency could send in a nurse. Under PCR, PGBA tells providers, you must submit a new pre-claim review when a discipline is added mid-episode.

If the PCR is for a recert, PCGA reviewers are demanding to see the Face-to-Face document from the original episode and plans of care from all episodes. In Bill Dombi’s opinion, they are not allowed to make these requests. Nevertheless, an agency cannot object without risking an automatic denial.

Emerging Solutions

On the optimistic side, some agencies have found a path or two through the chaos.

One agency produces cover sheets for physicians to sign. They include a list of all the documents the agency provided to the physician with a signature line that says something like, “I acknowledge that I have received the following documentation from ABC agency.”

Regarding the cover sheet idea, Bill Dombi said NAHC has presented such a form to CMS to look at and they have indicated it is acceptable to ask the physician to affirm the records he or she reviewed for your patient.

One agency is calling patients on the phone as soon as they know they have a non-affirmed PCR. They alert the patient that they will be getting a letter from CMS and telling them is has nothing to do with the quality of the care they will continue to receive.

IHHC has been in communication with the Illinois Medical Society, giving them information they can use to teach their member physicians about. The group is open to hearing more because it wants patients to receive the best care. These conversations will continue.

PGBA also seems to misunderstand what documents are required. Though CMS assured providers last June that PCR would pose no significant administrative burden, that providers would be asked to merely submit the same documents they submit now with final claims, Illinois providers are finding that PGBA is actually demanding all the same documents they request for an ADR. Many agencies have had to hire additional staff to handle the burden.

Physicians, tired of HHA demands for signatures and certifications early in the episode, are beginning to avoid home health altogether, sending patients back to the hospital.

CMS promised a 10-day turnaround when responding to PCR requests. One agency reports eight PCRs submitted before September 1 that had not received responses as of September 22. Many other agencies

The method of response is supposed to match the method of submission. Many agencies report that they submit electronically but receive responses by U.S. Mail or Fedex. PGBA offers no explanation for the chaos and confusion. CMS only states that all responses come back the same way they were submitted, even though they have been told this is not the way it has been happening.

PGBA is supposed to have a system that allows reviewers to match resubmission documents with documents from the original, denied submission. It does not have such a system. If it did, agencies would be able to send only the changed documents after a denial. Reviewers would be able to find the original and combine the two. Instead, resubmissions must include all documents, even the ones that needed no corrections.

Inaccurate instructions seem to arrive frequently from PGBA. One agency administrator reports, “I was told to list the names of all physicians in a practice because PCR reviewers would otherwise not know which physician in the practice is responsible for the patient. “This makes no sense,” Dombi reacted, “because Medicare’s policy is that you cannot have two different individual physicians, one the homebound certifier and another who completes the F2F document.”

In response, some smaller agencies are holding off on submitting PCRs until the dust settles, or until CMS gives up and suspends the pilot in Illinois until PGBA improves its performance. Some providers say they are holding recert PCRs but submitting them for new episodes. One larger agency said it wanted to hold off but could not. “We submitted 500 already and have 600 more being prepared.”

Searching for consistency
With all these errors and rules violations occurring every day in Illinois, both the state association and NAHC are calling for the pilot to be aborted, reasoning that if the system is not ready for the other four states it is not ready for Illinois either.

IHHC and NAHC acknowledge that the purpose of PCR is to get fraud and abuse under control. They question, however, the effectiveness of subjecting every provider to the same cure. IHHC’s Public Affairs Director Micah Roderick knows well that the association is aware of the fraud and abuse problem and supports all efforts to root it out.

“It helps no one,” he told us. “It gives the entire industry a black eye. But there have to be ways to tackle the problem without punishing everyone.” Besides, he continued, the bad guys will figure a way around it and only honest agencies will be harmed. He fears hospital readmission rates will skyrocket when agencies start closing or turning patients away because PCR is not being executed correctly.

Susan Platt, co-owner with her husband of Spoon River Home Health in Farmington, Illinois, reminded us that the MACs and ZPICs seem to have no trouble identifying abusive HHAs when they issue ADRs or place agencies on focused medical review. “They know who the bad guys are,” she moans, “why can’t they just go after them instead of making the rest of us jump through all these expensive hoops?” She added that she had asked that question of one CMS official who explained that “it takes six years to build a case against a fraudulent agency.”

NAHC’s Dombi agrees. “They have enough information now to figure out what is going wrong and what they have to do to fix it. They are not going to learn anything more by continuing in Illinois.”

©2016 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. One copy may be printed for personal use; further reproduction by permission only.


by Tim Rowan, Editor & Publisher,  Home Care Technology Report

While most of the blame for Palmetto’s [Palmetto Government Benefit Administrators (PGBA)– Home Healthcare Medicare Administrative Contrators for IL and other states] 80% denial rate in Illinois can be laid squarely at the feet of PGBA reviewers who have not been adequately trained in Medicare Home Health regulations, providers of Medicare healthcare at home services must accept that many of the pre-claim non-affirmations are justified. One of the responsibilities that accompanies the privileges of a professional license is to take as much care with the documentation that describes your care as you do with the care itself. With all its problems, Pre-Claim has shown that much more care is needed.[Rowan pinpoints the need for healthcare at home providers to rectify the clinical documentation crisis in [reporting care for] Healthcare at Home for Medicare beneficiaries. His view is affirmed by Bill Dombi of NAHC who advises that caregivers must redouble their efforts to become more professional and inclusive of all needed information of pre-claim review (PCR) submissions. The urgency of providers’ achieving a much higher affirmation of PCR claims, Rowan counsels, is critical for healthcare at home agencies ‘ staying in business.]

This publication has never been shy about discussing the clinical documentation crisis in Healthcare at Home for Medicare beneficiaries. Whether it is caused by clumsy software or excessive productivity expectations or inattentive clinicians, consultants and Medicare officials have long complained to us that clinical documents frequently fail to show medical necessity for many of the services we offer.

Now we have additional confirmation.
In a conference call with Illinois providers and the Illinois Homecare and Hospice Association this week, NAHC’s Bill Dombi made it clear. After speaking about Pre-Claim Review errors that are caused by PGBA reviewers he was quick to add, “We are also finding HHAs could be doing a better job. I don’t know how well you are screening documents you send but the ones you send to us are often absolutely deficient. You have to redouble your efforts to review your documents before you send them in. [Problems include] simple things such as missing dates and the like.”

While the bulk of this week’s Home Care Technology Report is devoted to calling CMS and PGBA to higher standards, we cannot leave the impression that all the blame is on the other side. Complete, bullet-proof documentation, which only results from setting high employee standards and providing frequent, comprehensive training, has long been an elusive goal in our field. If there is one good that has come from the pre-claim fiasco in Illinois, it is that it has exposed just how sloppy and unprofessional we can sometimes be.

We heard many comments this week expressing the hope that pre-claim reviews will weed out the criminals from out midst. There is just as much chance it will weed out honest agencies that fail to get their act together and start submitting documents that demonstrate homebound status and medical necessity, the two red flags pre-claim auditors and ZPICs look for first.

There are only two ways this situation can be fixed.
One solutions is to take Dombi’s advice and redouble our efforts to become more professional with the documentation we produce, review, and submit. The other solution is that problem HHAs will not be able to survive the next &– hopefully well-oiled and functioning –pre-claim system when it goes nationwide.

One provider on this week’s conference call reported a 61% PCR affirmation rate. Not ideal but certainly better than the 20% – 40% average affirmation rate across the state. So it can be done. The ones who do it are the only ones who will be making payroll and keeping the lights on a year from now.

©2016 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. One copy may be printed for personal use; further reproduction by permission only.


By Tim Rowan, Editor & publisher, of Home Care Technology Report

We received this notice from the Texas Association for Home Care and Hospice. They are taking a pro-active position on preparing for the day when CMS gives Texas a 30-day notice that pre-claim review will begin in that state.

This delay does not currently affect Illinois and is NOT a permanent repeal of PCR. CMS squarely blames the providers for the implementation issues with PCR rather than accepting any responsibility for the unworkable process. PCR WILL RETURN. [This article presents many comments by providers from the Illinois Homecare and Hospice Council (IHHC) on difficulties encountered submitting pre-claim review (PCR) submissions to Medicare.  A focus on needed education for providers working with PCRs is presented from representatives of the Texas Association for Home Care and Hospice (TAHC&H ).]

 However; this delay allows the industry more time to advocate for a permanent solution to PCR. TAHC&H will continue to advocate for a permanent solution to PCR and will continue to work with the other states to combine our efforts in one consistent and strong message to CMS and our Congressional supporters.
 You should continue to press Congress to require CMS to work with stakeholders toward a permanent solution to PCR. The provider experiences below are good talking points to share with congress. Illinois providers are the bell weather to what is in store for each of us when the delay is lifted. Here is what providers in Illinois are saying just last week.
  • Some IHHC members report having been told that electronic signatures from physicians are not acceptable.
  • Some IHHC members have been told that APNs cannot conduct face-to-face encounters. IHHC has shared information about the Illinois Nurse Practice Act’s designation of APN as the legal way for licensed nurse practitioners and clinical nurse specialists to sign their names in Illinois-we are awaiting a response.
  • There is still no update from Palmetto on a fix to the glitch related to claims with “To” dates on or after August 3, 2016 that are incorrectly being Returned to Provider (RTP) (Reason code C5467).
  • Several providers have reported that they have been waiting weeks for PCR decisions. When they call the PCC they are being told that Palmetto is looking into it and information should be provided in about 10 days.
  • Systems glitches make submitting PCR packets extremely arduous, prompting CMS to recommend providers sending their PCR packets by Fax.


TAHC&H will continue to offer the PCR education scheduled for October and November in partnership with Palmetto GBA. This is currently just a temporary delay and we must be vigilant in ensuring agencies are prepared. The root-cause issues related to documentation expectations by Palmetto GBA still exists. They have much to share about the Illinois experience and what we are finding is that many of the practices you may employ today are NOT working with PCR; specifically use of a F2F form with MD narrative, for example.

Additionally, as with all in-person workshops performed by Medicare Administrative Contractors (MACs), providers must sign in with their Medicare Identifier. CMS is evaluating the educational uptake and the provider community’s interest in ensuring they are prepared for PCR.

YOU MUST BE READY! Register today and do not miss out on this opportunity to change your practice in preparation for this project.

This article originally appeared in Tim Rowan’s Home Care Technology Report ( It may be copied and distributed freely.


by Tim Rowan, editor and publisher, Home Care Technology Report

TRY THIS: Open Google in your browser and search for “Home care” + “name of your city.” Study these results for a minute and see if this is what you find: two or three ads at the top, paid for by one of your competitors, followed by a list of local agencies, arranged in what appears to be random order. Now remove the city name and search again. You have just experienced the difference between regular Google search results and the new “Google Local.”

Looking more closely, you will notice that the order is not actually random. All else being equal, Google has started pushing businesses with the most, best, and most recent customer reviews to the top of their local search results, which is where you land if you include a location name in your search string. Companies with no reviews or mostly negative reviews will appear somewhere on page two or three. You should read a few of these reviews; some will lavish praise, others will complain. People are like that. [Rowan proceeds to describe the importance of businesses’ seeking out positive reviews to post online at,. He goes on to describe how the new “Goggle Local” promotes the top rated/reviewed companies. He also stresses the Internet”s (especially’s) marketing value, placing this venue well above  traditional marketing forays.  The very vital importance of posting positive reviews from satisfied customers of your businesses on is underscored. The importance of companies’ gleaning and posting positive reviews on today, especially in the healthcare at home industry, is described in detail, with examples provided of successful marketing on by other industry representatives who get top ratings by]


Listings that have received at least five reviews also display Google star ratings. Those with mostly positive reviews get more stars; those with poor reviews get fewer. Five-star companies tend to appear at the top of the results list, immediately under the paid listings, (which most people tend to ignore). The top three listings on the list also appear on the accompanying map. These businesses get about 65 percent of shopper phone calls, marketing researchers say.

In these competitive times, your goal of course is to be one of the three, but how do you do that? Positive reviews are rarely spontaneous. Companies that make the top three have made concerted efforts to encourage their happy customers to write reviews.

This is why you need to start paying attention to this. Getting at least five reviews does not just happen. Even if you have fewer than five reviews and are not eligible to have your stars displayed, your place on the results list is determined as much by your positive and negative reviews as it is by your web site’s SEO strategy. If you only have one review and it is a bad one, chances are you will find your listing somewhere around page 15.

Don’t say ‘so what?’
This new way in which the Internet encroaches into your established, familiar marketing plans cannot be ignored. Suppose you pay for a large Yellow Pages ad or even a recurring TV spot. Even if these have your phone number prominently displayed, research has found that 88 percent of people will still look you up online before they call you up.

When they Google you, if they find one bad review and no positive ones, 88 percent of the money you spent on those ads goes to waste. Remember the line you’ve heard so often, “The Internet Changes Everything?” One of the things it has changed is human behavior, particularly when that human is in the persona of a consumer. For reasons no one can completely explain, people trust the online comments of perfect strangers.

Therefore, if you have always had a word-of-mouth marketing strategy, you must accept that Google reviews is where word-of-mouth happens today, not the corner barber shop. For this reason, you must keep track of your online reviews. When you find a bad one, you have to spring into action. Ignoring them does not make them go away.

To get some perspective, take a peek into how other industries are way ahead of us. This time, instead of searching for “Home Care,” search for “Home Cleaning Services” + “your city.” You will find local companies with dozens of reviews and star ratings. If you need further proof, search for auto mechanics, Chinese restaurants, or dentists.

As this experiment should show you, other industries have discovered how to take advantage of the billion dollar infrastructure Google has created for us. Home care has not yet, which means the first to grab this strategy will be the only ones to benefit from it. The time has come for home care to learn what other sectors already know:

  • Google reviews cannot be ignored.
  • Negative reviews can kill your business.
  • There are solutions that enable you to keep 24/7 surveillance on Google reviews and that make it easy for your staff to encourage customers to write positive ones in order to raise your average star rating.

There is probably no room in your marketing budget to hire someone to keep a 24/7 eye on Google, not to mention Yelp, Facebook, Twitter, and all the review sites focused on health care. Fortunately, there are services available, usually for less than $200 per month, which will automate the process. The question is whether it is worth a couple thousand dollars per year to avoid wasting most of the rest of your marketing budget. The publisher of this newsletter has partnered with an expert in the field to bring these 21st-Century marketing strategies to healthcare at home providers. That’s how important we think it is. To grab the opportunity, start by reading about this new consulting service and software tool at before your competitors do.

©2015 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. One copy may be printed for personal use; further reproduction by permission only.


By Tim Rowan, editor & Publisher, Home Care Technology Report

One contributing factor to increased hospital readmissions and Emergency Department utilization is behavioral health. Whether a person suffers from substance abuse as a result of mental health issues or develops behavioral issues because of drug use, this person may visit the ED 100 to 200 times per year. A federal agency, the Substance Abuse and Mental Health Services Administration (SAMHSA), has not been reauthorized since the 1990’s even though 11 million Americans suffer from severe schizophrenia, bipolar disorder, and major depression.

We learned about the crisis, and a proposed solution, in a conversation this week with Kevin Scalia, the EVP of Corporate Development for Netsmart, the healthcare information technology company that recently acquired Allscripts’ healthcare at home division. (See HCTR, 3/30/16, “Allscripts Reinvests in Home Care“) [Rowan provides extensive details about Scalia’s work affecting governmental passage of numerous bills for mental healthcare legislation reform. In addition, Rowan notes, Scalia has important ties to Netsmart and the industry coalition’s  support of passage of the so-called “Integrating Behavioral Health Through Technology Act” (S. 2691), sponsored by Sen. Sheldon Whitehouse, D-R.I. This measure would create a $250 million, five-state pilot program with health information technology financial incentives for psychiatric hospitals, community mental health centers, social workers, psychologists and addiction treatment providers. Additional work in which Scalia is involved  to rally support for passage of important bills to benefit persons needing mental and behavioral health care is noted in detail.]

Scalia  also notes that the success of Meaningful use is evidenced by its rolling out $30 billion into EMR rollouts, so that today every hospital and physician that is going to have an EMR has one. Now, we are rolling into value-based payments, coordinated and integrated care to try to keep people out of hospitals, especially the chronically ill.

Scalia is urging both sectors, behavorial health and healthcare at home, to get behind Senate Bill 2680, the “Mental Health Reform Act of 2016.” The House has already passed its version (H.R. 2646, the Helping Families in Mental Health Crisis Act) but without the amendments that the Behavioral Health IT Coalition were expecting. Scalia also notes that integrating mental health and addiction treatment services with the rest of medicine is essential to reducing the mortality rate among patients with serious mental illnesses,  and he notes that Netsmart has interest in  joining forces with Allscripts Home Care to follow their  belief that post-acute- and community-based services must be the first choice for care and treatment services.was very successful,” he continued. “It rolled $30 billion into EMR rollouts, so that today every hospital and physician that is going to have an EMR has one. Now, we are rolling into value-based payments, coordinated and integrated care to try to keep people out of hospitals, especially the chronically ill, which is wh

Lobbying efforts are now focused on the Senate bill and the restoration in an eventual conference committee of a provision that would give post acute providers the kind of financial support for deploying EMR systems that has been so successful for hospitals and physicians. That provision was removed from the House version before passage last spring

A bipartisan bill, S. 2680 was reported out of the Senate Health, Education, Labor and Pensions committee in March under the leadership of HELP Committee Chairman Lamar Alexander, R-Tenn., and Ranking Member Sen. Patty Murray, D-Wash. The House version was also sponsored on both sides of the aisles, introduced by Rep. Tim Murphy, R-Pa., and Rep. Eddie Bernice Johnson, D-Texas.

“The Senate has a once-in-a-generation opportunity to pass comprehensive mental health legislation by taking up S. 2680 in September before the fall recess,” Netsmart’s Scalia said. “Passage of this legislation would create the alignment needed for a conference committee to sync during this session of Congress on a final bill benefiting millions of people suffering from mental illness. It is urgent because, if they do not pass it and send it to the President’s desk before the November election, all bets are off. Anything could happen, including years of delay.”

Technology also in play
Scalia also told us that Netsmart and the industry coalition support passage of the so-called “Integrating Behavioral Health Through Technology Act” (S. 2691), sponsored by Sen. Sheldon Whitehouse, D-R.I. This measure would create a $250 million, five-state pilot program with health information technology financial incentives for psychiatric hospitals, community mental health centers, social workers, psychologists and addiction treatment providers.

Netsmart views Senator Whitehouse’s bill as an important first step to helping resource-challenged providers of mental health services fully utilize technology for coordinated, integrated care with physical health providers.

“Integrating mental health and addiction treatment services with the rest of medicine is essential to reducing the mortality rate among patients with serious mental illnesses,” said Scalia. “Our interest in joining forces with Allscripts Home Care comes from our belief that post-acute and community-based services must be the first choice for care and treatment services. Our economy simply cannot sustain ED and hospital overuse.”

“Meaningful Use was very successful,” he continued. “It rolled $30 billion into EMR rollouts, so that today every hospital and physician that is going to have an EMR has one. Now, we are rolling into value-based payments, coordinated and integrated care to try to keep people out of hospitals, especially the chronically ill, which is where we spend so much money. So we have to look at who the most expensive consumers of healthcare are. They are people with behavioral health issues, people in long term care, and people who are chronically will and are being treated at home. What do all these care centers have in common? All of them were excluded from Meaningful Use EMR funds by the American Recovery and Reinvestment Act of 2009.

“If our goal is to keep people out of hospitals, we’ve taken the people who are the gatekeepers, who can best keep people out of hospitals, and we haven’t given them any funding for technology to do home based care, care coordination and the like. So we started working immediately upon the passage of the HITECH Act to lobby on behalf of our behavioral health clients to get them included in the Meaningful Use program so they could afford the technology needed to integrate with physical health.

“Because at that point we had bifrocated the healthcare system where people who had mental health issues were treated in psych hospitals and community behavioral health centers and those people were dying 25 years earlier than people without a mental illness, not because of mental illness but because of co-occurring physical illnesses. If you went to a hospital with diabetes and bipolar disorder, they would treat your diabetes and not ask you about your bipolar. Our view is that we need to connect the head back with the body and integrate physical health with mental health.”

Netsmart is urging all healthcare at home providers to join them in urging the passage of the “Mental Health Reform Act of 2016” (S. 2680) and the “Integrating Behavioral Health Through Technology Act” (S. 2691). A summary of 2680 is available here. If you do not already have the direct phone number for your Senators, you can call the Senate switchboard at (202) 224-3121 and ask for your Senator’s office.

About BHIT

Netsmart is a founding member of the Behavioral Health IT Coalition, a consortium of 12 key organizations established in 2010 to advance public policy for technology to improve the lives of people with mental health and addiction disorders. Members include the National Council for Behavioral Health and the National Association of Psychiatric Health Systems.

According to BHIT’s vision statement on its web site, “All persons in need of mental health and addiction services receive high-quality, coordinated care from their behavioral health and primary care providers, utilizing healthcare information technology (including Electronic Health Records) as a key element in delivering services and care for the “whole person.”

©2016 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. One copy may be printed for personal use; further reproduction by permission only.


by Audrey Kinsella

An encouraging case study in the use of a user-friendly home telehealth and patient engagement system comes all the way from Amsterdam. Live Expert® is a remote patient monitoring and video consultation system from ClairVista, a Chicago company with an office, and a large customer, in the Netherlands. Unlike early telehealth systems that were often marketed as a comprehensive solution or as a one-stop-shop for software and peripherals, LE seems to be more of a supermarket.

ClairVista has included patient monitoring equipment that provides tracking data used as bases that are used by clinicians for videocalls, in person visits, and educational and other contact with patients. The system works on smartphones and tablets as well as terminals and kiosks. Where LE is different from early systems based on video conferencing technology, it requires no pre-steps to initiating a video session, such as software downloads, account creation, or even the need to know in advance the specific person to contact. [Other ease-of-use features particularly for elderly clients  are noted. ClairVista’s vice president for telehealth, Doug Irvin, explained the company’s concept of simplicity for users. “We believe that the system’s simple, one-touch-to-connect design works more like an appliance than complicated technology. Even with the abilities to transmit biometric data, present educational content, and join video calls with multiple clinicians simultaneously, it is still well suited to all types of patients.” Most noteworthy in this company’s profile  is a focus on the use of this system by large numbers of intellectually disabled/developmentally disabled (ID/DD) persons in the Netherlands, whose caregivers describe the value of this system for fostering independence in members of this typically needy client population.]

To make using the system as easy as possible for elderly patients, LE leverages advanced call management capabilities such as automatic call routing by skill/language/location, active queue management, and live video call transfers.

In a recent telephone interview, ClairVista’s vice president for telehealth, Doug Irvin, explained the company’s concept of simplicity for users. “We believe that the system’s simple, one-touch-to-connect design works more like an appliance than complicated technology. Even with the abilities to transmit biometric data, present educational content, and join video calls with multiple clinicians simultaneously, it is still well suited to all types of patients.”

Even with a supermarket of features, Irvin insists, LE is not out of the reach of the typical elderly patient, no matter how technologically adept. “Our developers have been told not to dumb down the offering,” he told us. “Of course, all organizations prefer simple solutions, but we simplify the experience for patients while providing a feature-rich interface for clinicians. We are focusing our efforts on connecting with healthcare at home organizations that require a powerful but simple-to-use system.”


Case study
One early user is Netherlands-based Stichting Philadelphia Zorg, which cares for about 7500 at-home clients. This company is revolutionizing care for the intellectually disabled/developmentally disabled (ID/DD) population by replacing a number of traditional home visits with video care sessions. With a single click on a website or tablet, patients can (and do) connect with a caregiver whenever they need help.

Upshot: Caregivers of these patients report spending more time providing care and less time managing and traveling to appointments. This service model has significantly increased the availability and accessibility of care for Philadelphia’s clients while reducing total cost of services. In the past, patients’ issues often waited until the next scheduled visit. Now, Philadelphia’s caregivers are available on-demand, 24/7, when a immediate intervention or assistance need arises.

And, despite a recent 25% reduction in Netherlands government funding to healthcare at home program services (U.S. providers are not alone in this plight), Philadelphia has been able to transform and expand its availability of services. For staff, the remote video-caring concept with Live Expert means a new way of working. As one such clinician notes: “Supporting our patients this way requires a different skill set. It is important to support our patients to live independently. We stimulate achieving this goal in every possible way. With the use of the LE Telehealth solution, helping our patients to achieve independence has become more do-able.”

Audrey Kinsella, MA, MS, is HCTR’s telemedicine reporter. She has written on home telehealthcare and new technologies for home care service delivery for 20 years, in 6 books, multiple web sites, and more than 150 published articles. Audrey can be reached at or 828-230-0895.

©2016 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. One copy may be printed for personal use; further reproduction by permission only.


By Tim Rowan, Editor & Publisher, Home Care Technology Report

Fifteen minutes from Palmetto Government Benefits Administrators, the Home Health Medicare Administrative Contractor for Illinois and other states, lies the home ballpark of the Columbia Fireflies, the  Single A farm team for the New York Mets. Just a quick drive down South Carolina Highway 227, any PGBA executive might learn a valuable lesson with a visit there.

He or she would find that, in spite of all the sports page headlines, former Heisman trophy quarterback Tim Tebow is not there. He has not made it as far as the lowest minor league rung yet. After signing a contract with the Mets, he was sent directly to their Instructional League team in Port St. Lucie, Florida. They wisely decided he needed months of intensive training before he, though a world-class athlete, would be ready to face even a minor league pitcher.

Were PGBA executives as wise as Mets executives, they would have done the same thing with all the new hires they brought on board with the extra money CMS gave them to manage the tsunami of paperwork expected from Medicare’s 5-state Pre-Claim Review experiment. Had these rookies been properly trained before being thrust to the front lines of document review, it is possible CMS might have avoided the fiasco that is going on in Illinois, the first state to pilot PCR.

Instead, due to what appears to be rushed, superficial training, PGBA PCR reviewers are making so many mistakes they are causing increased costs for Illinois home health providers, the unnecessary expense to Medicare of increased hospital readmissions, and extreme consternation among beneficiaries. It is this seemingly endless list of mistakes that forced CMS to postpone scheduled start dates for the same experiment in the other four states, though their announcement suggests it is Illinois HHAs that need more education. [Specific details about misinformation provided by CMS officials on submitting PCR claims by IL providers are noted in this article, along with the resulting difficulties experienced state-wide. Arguments about the PCR claims process noted by government and NAHC representatives are provided, and moves toward halting the PCR process in other states are described. The effects on patients of having healthcare at home agencies’ PCR denial rate skyrocket to 60% to 80% are discussed.]


All of these problems were avoidable yet predictable. PGBA, it will be remembered, is the MAC that blatantly misinterpreted the intent of Congress with regard to the Face-to-Face certification rule, denying thousands of claims over typos and dates placed on the wrong line instead of using the rule to expose fraud and exclude criminals from the industry’s midst. It surprises no one that Illinois is already reporting a 60% to 80% denial rate of pre-claim reviews even though their claim denial rate was nowhere near that high before PCR began.

What CMS told you
When Jeane Nitsch, Director of the CMS Division of Compliance Projects and Demonstrations, and Jennifer McMullen, member of the CMS Pre-Claim Review Demonstration for Home Health Services Team, told Open Door Forum listeners on June 14 how pre-claim would work, there was a palpable undertone to every listener’s question. It said, “Well, that’s not going to work!” They were prescient.

Nitsch and McMullen said: Illinois is experiencing:
You will submit the same documentation you submit now with your claims. The only difference will be that you submit it earlier. Denials (called “non-affirmations”) are returned for missing documents that have never been required with claims, only for ADR responses. E.g. For recerts, reviewers are demanding to see every plan of care from every previous episode and the F2F document from the first episode, which they are not authorized to do.
Your response will be issued within 10 days. 11-20 days is as common as 10 days.
Your response will be sent to you in the same format you sent the PCR documents. I.e. electronic submissions will receive electronic replies, fax to fax, U.S. Mail to U.S. Mail, etc. Response formats are random. Many submissions via PGBA’s “eServices” portal receive U.S. Mail replies. Some come by Fedex. When that happens, the result in the letter does not appear on the portal.
CMS will educate physicians on the need to sign your documents at the beginning of an episode. No physician education appears to have been done. Most agencies report they themselves are informing their referring physicians for the first time of the existence of PCR.
We are providing additional funding for the MACs to hire and train enough staff to manage the additional work. But we decided HHAs will not need additional payments as the workload is expected to be minimal. Most Illinois providers report the need to dedicate two or more FTEs to the unexpectedly massive additional paperwork processing burden.
This will be an educational tool to teach agencies how to submit the correct documentation, making claim denials less likely. Non-affirmations bear no indication what is wrong and how to fix it. They are marked “non-affirmed” or “education,” nothing more, no explanation as to why it was denied, on which document the error can be found, and what sort of error it is.


(For more Illinois experiences, see “Illinois Providers Frustrated, Angry, But Not Powerless” elsewhere in this week’s issue.)

With regard to that last Illinois experience, we were told by Micah Roderick, Public Affairs Director for the Illinois Homecare and Hospice Council, that members tell him it is like getting back a multiple choice high school quiz with a D- grade but none of the wrong answers redlined. “How do you learn from that?” he asks, rhetorically. “How do you learn from your mistakes and submit a corrected PCR the next time if you don’t know what your mistakes are?”

He answered his own question. “Some of our members have sent in the same exact documents with no changes after getting a non-affirmation. The second time, it gets affirmed. Go figure.”

Although this last experience is all the proof one needs to realize that inadequate PGBA reviewer training is the culprit, there is plenty more proof. In a September 22 conference call, NAHC’s Bill Dombi summarized a book-length list of stories his office has received from Illinois providers of unfounded non-affirmations. He concludes, “Many of these non-affirmations are based on reasons that simply do not exist in the rules, not just in home health but anywhere in Medicare.”

Deflecting blame
In its September 19 announcement that Illinois would continue in the PCR experiment but the other four states would not begin as scheduled, CMS made it clear how it is going to spin the problems that led to the decision to delay. Most Illinois providers read the statement, “Based on early information from Illinois, CMS believes additional education efforts will be helpful before expansion of the demonstration to other states” as squarely placing the blame on HHA incompetence. Nowhere has a CMS staffer made mention of errors on the part of PGBA, not in writing nor in conversations with NAHC.

In fact, IHHC has already found the need to defend its members with its Senators. Staffers for Democrat Dick Durbin and Republican Mark Kirk have been rebuffing provider and association pleas to help them convince CMS to turn off PCR in Illinois by quoting from a letter they received from CMS. In the letter, CMS makes it clear that provider incompetence is the problem and that they have done everything properly to make sure PCR works efficiently. Most often, phone calls to Senators are not returned; instead terse letters are sent repeating the CMS point of view.

That door finally cracked just a little this week when one agency owner somehow got past Senator Durbin’s defensive line. Susan Platt, of Spoon River Home Health Services in Farmington, outside Peoria, told us that the Durbin staffer in charge of healthcare affairs did finally call her back, after she had left many messages. He appeared to accept the possibility that the CMS slant might not be entirely accurate. IHHC has promised to help Ms. Platt pry that crack open a little more.

Keeping the lid on for the other four
IHHC and NAHC are urging every HHA in the five pilot states to contact their Representatives and Senators as soon as possible, telling the Illinois/PGBA story. Until CMS and its contractors figure out how to teach the rules accurately to their reviewers, they say, Texas, Florida, Michigan and Massachusetts will certainly experience the same problems Illinois is reporting.

Appealing to Florida’s Congresspersons and Senators does seem to have been what put pressure on CMS to postpone PCR, Dombi opined during his 9/22 conference call. Marco Rubio and, of course, all Representatives are up for re-election. That makes politicians unusually receptive to responding to constituent demands.

“This is creating a crisis at a bad time for elected officials,” Dombi figures the bureaucrats are thinking. “CMS does not want to find itself in middle of an election fight because of problems caused in five states, especially Florida, which is so important in the electoral college vote count for the Presidential race.”

What about the patients?
Illinois Senator Kirk’s office said it is only interested in receiving stories about Medicare beneficiaries not getting the care they need. Of course, that has not happened yet but IHHC and NAHC are certain it will. With a 60% to 80% PCR denial rate, they say, HHAs are soon going to have trouble meeting payroll. If they resort to layoffs, a possibility, they will start turning away referrals. In rural areas, with no in-home services available, Medicare beneficiaries will have to move to Skilled Nursing Facilities or hospitals. The end result will be skyrocketing Medicare costs.

Before that happens, patients are already distressed. One of the little known provisions of the PCR experiment is that a letter is automatically generated to the patient with every non-affirmation. Letters inform the patient that their home health agency has received a decision of non-compliance with billing regulations. Agencies have been receiving alarmed phone calls from frantic elderly patients, asking if they are being cared for by bad people.

©2016 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. One copy may be printed for personal use; further reproduction by permission only.


by Roger McManus, MBA (who has held several positions as Director of Strategic Relationships). 

In a world where over 80 percent of prospective consumers will see your ad, but look you up online before calling your place of business, your placement in a local Google search is critical. A local search is triggered when someone types in “home care” and the name of the city in which you operate (e.g. “Home Care Canton Ohio”). It is different from typical searches because the searcher defines the geography in advance and Google treats it differently when the results are displayed.

August Surprise
Before August 7 of last year, a local Google search showed up to seven listings on the first search page beside a map showing where the businesses are located. This was called the “Map Pack.” These results included addresses, phone numbers, reviews and the location’s website.

The Pigeon Play
Google’s “Pigeon” update really did impact local search by shifting searches from being city-wide to being more neighborhood localized. Again, this move toward improvement works to help searchers. This geo-positioning search is also helpful to local businesses by making those closest show up higher in the rankings for that particular searcher. best take advantage of the “Pigeon” update, use more localized descriptions of your neighborhood in your directory listings and website. Let Google know where locals think you are. For example, you may be in Cincinnati (population 300,000), but locals would think of your store as being in Kenwood (population 6,000 – but with a Cincinnati address).The goal of every online-aware business owner is to be in the “Map Pack” (Snack Pack). The localizing impact of Pigeon actually narrows the competition somewhat making it easier to accomplish your objective – particularly if your competition is not paying attention. Even when seven businesses were listed, the top three got about 64 percent of the clicks. Now that there are only three, your diligence is all the more critical. It is too soon to have meaningful measurements, but the number has to be significantly above 64 percent. Businesses listed at the top without the searcher having to look any further will obviously get more traffic (and, therefore, more new clients) than those showing up in Google purgatory. It stands to reason the rivalry for this space will become much more competitive. You have the opportunity to get a head start if you act now. [McManus provides succinct details about how Google continues to consistently change how business listings are presented on pages and presents needed tips to business owners marketing their sites for staying in top rankings on Google displays by, for instance, consistently seeking out and posting positive reviews by your business’s customers as well as very precise NAP –i.e., name, address. and phone number information.]

Since that date, the list has been trimmed to three and has been dubbed the “Snack Pack” or the “Stack Pack” depending on who is describing it. This is a massive change and one that dramatically impacts local online marketing for any business. Because home care agencies are inherently local (even national chains or franchises), it represents a 57 percent reduction in page-one Google real estate.

Perhaps the only thing that is consistent about Google is that it being constantly altered. It is said that Google’s algorithm is changed between 500 and 600 times per year – about twice a day! Most of these changes are minor tweaks but some come in big, dramatic bundles such as the Map Pack change. Some of the larger ones in the past have been named after animals that start with the letter “P”.

For example, online (non-local) marketers were powerfully impacted by the introduction of Google’s “Penguin” program change and “Panda” before that. These did not really impact local businesses because they were both designed to improve the quality of the results people would get if they did general organic searches on Google. This hurt those who tended to use weak content to “spam” searchers and demonstrates how Google is dedicated to change in the name of improvement.

If you are already in the top three
Even if you are already in the top three, you cannot relax. This change in the google display system will only serve to awaken those who did not make the cut from seven to three. You can expect a redoubling of their efforts to displace you from the top. You can expect them to get more aggressive with cleaning up their listings and encouraging reviews (they might even read this article!). Over half of those appearing in the 7-packs are suddenly gone, and everyone will want a shot in the new 3-pack. Since they have nowhere to go but up, do not be surprised when a competitor sneaks up out of the dark to displace you in the top rankings. It is a very fluid game and there is no room for complacency.

Institutionalizing the Process
Your task, therefore, is to consistently collect positive reviews. The good news is that there are new systems on the market to facilitate this task by allowing your field staff to engage patients and collect their reviews. These systems then automatically post your patients’ reviews on Google, or another review site, before your clinician or aide even leaves the residence.

A Hint at the Future
Google likes to test changes in small subsets of their giant world before committing to broad alterations. One thing Google is testing in the restaurant space is a searcher-triggered, drop-down option for consumers to select the minimum star level they want to see. If you want to see only four-star and above listings, you can do that. While this does not currently impact home care agencies, keep an eye out for it to become universal. Your patients’ reviews will become all the more critical in years to come.If you are in a densely populated area or you have lots of near-by competition, you should pay serious attention to those star-ratings now, so you are prepared should Google pull the trigger on expanding the rating selection system. Do not count on getting advance warning about such a change. Google will want to avoid business owners spamming reviews in preparation. If you already have a rating of four-stars or more, you don’t have much to worry about. If not, get started now collecting reviews from your happiest customers.Also, there is the reciprocal. Given that reviews are getting much more emphasis in the ratings for local results, businesses with few or no reviews are definitely at a disadvantage. This is a real disadvantage that costs real dollars. Far too many business owners – not just home care agencies – are not giving this adequate attention.

The text displays a link that directs the customer to your Google page where customers can give you a star rating and leave a review from their cell phones – which means from their own IP address, a Google requirement for a legitimate review. Yelp and Facebook posts are other options in this system; plus, the program can ask up to five marketing research questions. Information about one such system, available from the publisher of this newsletter, is available at

What else should you be doing?
Besides collecting more positive reviews, it is important to address whatever negative ones that may crop up. If a service problem led to the review, address it internally. If the review calls for a response, deal with it in a proactive way. Note: This does not necessarily mean you address the issues in public by responding online. Sometimes it is best to limit the number of times an issue is aired publicly. Private communication is often the best strategy to approach an unhappy customer. A successful exchange can sometimes get a negative review quietly removed.

It won’t stop.
Google will constantly change. As much as it seems so, it is not just to keep you off balance. Google’s objective is to make sure people using its search engine get the best, least-spammed results available. Sometimes it makes life difficult, but those business owners who are paying attention will be able to take an ethical advantage over those who are not.

NAP Consistency
There are dozens of sites across the web that list your business and the details about it. Most important among these details is what is called the NAP. This stands for Name, Address and Phone number. As simple as that sounds, it is critically important to boost your Google ranking. Right or wrong, be consistent. And, that means be consistent on every item like Main Street vs. Main St. It does not matter which, just as long as it is consistent across every listing online.

Use every advantage you can. Not only is it important that the NAP is accurate and consistent, but Google (and other sites) allow you to add many elements to your own listings. These include a listing of your website, a description of your business (use keywords people might use to search for what you do), your hours of operation and pictures of your business and personnel. Every little bit counts.

©2015 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology One copy may be printed for personal use; further reproduction by permission


By Tim Rowan, Editor & Publisher, Home Care Technology Report

There was a day when Internet users anxiously awaited the release of the newest and fastest modem so they could experience blazing connectivity up to 56k. Then again, there was also a day when K-Mart sold black and white televisions.

Memories like these arose when we saw the announcement last week that Novitas Solutions EDI will no longer support dial-up connectivity after October 24, about five weeks from now. The company notified EDI trading partners connecting to Novitas via dial-up modem that they will be unable to connect for claim submission and/or report retrieval as of 12:01 AM EDT on that date. They must begin to use another connectivity method for claim submission and report retrieval such as: Secure File Transfer Protocol, Direct Data Entry (DDE) (Part A), or Novitas EDI’s free portal, Novitasphere (Part B). [This article provides details about Novitas’s assistance to dial-up modem users in transitioning to higher-speed services through MedTranDirect, a CMS Certified Network Vendor.]


This change will only affect EDI trading partners connecting via dial-up modem. Providers using a billing service or clearinghouse were encouraged to ensure they have updated their connections to Novitas as well.

Novitas customers using PC-ACE can continue to use this software to create claim files but they will need to enroll to send claims through the Novitasphere Portal (Part B only) or purchase a connection through an approved Network Service Vendor. Software vendors that provide connectivity through Novitas must remove the dial-up number from their software. If a provider does not know how they connect, they should ask their software vendor for assistance.

In a related announcement
MedTranDirect, a CMS Certified Network Vendor, is making an effort to remind providers that they are ready to help transition to their solution. MEDTran Direct provides secure, high-speed Internet connectivity for claim file transfer and remittance, online eligibility, and access to CMS’s Common Working File.

The Kansas City-based company also helps hospices experiencing claims denials over the Notice of Eligibility rule. See our earlier news stories about NOE Tracker by going to our main web site,, and clicking on “Search Articles.”

©2016 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. One copy may be printed for personal use; further reproduction by permission only.


by Michelle Boasten, humanitarian and social entrepreneur, and founder of “You Can Care, Inc,”as well as founder of EVV (electronic visit verification).

Last month, Procura sponsored a one-hour webinar titled “Medicaid Doesn’t Have to Be Complicated.”  Industry veteran presenters Stewart Campbell and Scott Brashears reached out to Medicare Home Health Agencies as well as Private Pay Agencies seeking to dip their toe into the deep and treacherous waters of state Medicaid plans and Home and Community Based Waiver Programs. The sage advice offered to “Medicaid newbies” was to get educated first. Start by learning one program in one state. Each program is different and each state is different. This profound program individuality makes national scaling challenging and narrow profit margins leave little room for error while demanding both operational efficiency and client volume. [Details about this webinar’s presentation, which noted the ultimate failure of a large Texas healthcare at home agency of expanding into Medicaid billing but also offered advice on ways other agencies could to well in fording Medicaid pitfalls.]

Scott Brashears

Scott Brashears

The August 17 webinar was recorded and remains available from Procura. It presented experiential insight as Procura worked closely with a large Medicare Home Health agency in Texas that experimented with expanding its Medicaid reach to include programs in Indiana and Ohio.

Ultimately, that Medicaid experiment failed.

The company decided it had not gained the profitable traction needed to substantiate the investment of time and money. Tips presented by Procura offered webinar participants the opportunity to learn from the mistakes of the profiled agency. Eye-opening stories of pitfalls encountered allowed listening agencies a peek into another agency’s experience expanding, perhaps too quickly and with too little preparation, into the Medicaid space.

As the webinar closed, Procura offered a generous, two-hour consulting opportunity to help other agencies work through the beginnings of their Medicaid education journey. It would be wise to take Procura up on this offer as it may increase one’s chance of success by pointing out “big money traps” to avoid, traps that can sink an agency’s ship in the deep and treacherous Medicaid waters.

To review the Webinar click here.

Michelle Boasten is a humanitarian and social entrepreneur. She is the Founder of “You Can Care, Inc.” an IRS 501(c)3 non-profit. Michelle has invented and developed a web and mobile incentivized volunteer caregiving platform to tackle the twin issues of caregiving and student loan debt.
Prior to “You Can Care,” Ms. Boasten founded EVV (electronic visit verification) in 1996. By 1998 the product was patented and today more than 50% of all home health agencies are required and mandated by law to use an EVV system to evidence accountable caregiving activity. 

©2016 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. One copy may be printed for personal use; further reproduction by permission only.