In 2016, CMS began rolling out a pilot program to enforce a more proactive oversight strategy on Medicare home health claims in an effort to reduce fraud and waste. The ultimate goal was to reduce improper payments and the cost of additional documentation and resources it takes for CMS to chase them. This “Pre-Claim Review” demonstration subjected home health agencies to additional billing scrutiny and red tape.
Home health agencies (HHAs) disliked a lot about the demonstration. After a rocky start in Illinois, industry organizations and leaders strongly voiced their opposition to Pre-Claim Review, prompting lawmakers to push for a delay in Florida implementation. In April 2017, CMS then announced an indefinite delay to evaluate the program. During this pause, home health agencies in Illinois were able return to normal claims submission while CMS worked to revise the demonstration. Meanwhile, CMS considered a number of changes in response to stakeholder feedback.
In May 2018, CMS announced an updated version of Pre-Claim Review called “Review Choice Demonstration” (RCD). In response to public comments, the demonstration incorporated more flexibility and choice for providers, as well as risk-based changes to reduce burden on providers demonstrating compliance with Medicare home health policies.
The new demonstration offers home health agencies three options:
- Pre-claim review – Home health providers must submit pre-claim documentation on all claims.
- Post-payment review – A new option for providers, this allows home health agencies to submit their claims for review after receiving payment.
- Opt out – Facilities can completely opt out of pre-claim and post-payment review, but will take a 25% reduction on all Medicare claim payments and make them eligible for review by Recovery Audit Contractors.
CMS said RCD better positions it to identify and prevent fraud, protect beneficiaries from harm, and safeguard taxpayer dollars to empower patients while minimizing unnecessary provider burden. RCD also helps ensure that the right payments are made at the right time for home health service through either pre-claim, prepayment, or post–payment review, protects Medicare funding from improper payments, reduces the number of Medicare appeals, and improves provider compliance with Medicare program requirements. The demonstration will not delay care to Medicare beneficiaries and does not alter the Medicare home health benefit. It does not create new clinical documentation requirements. HHAs will submit the same information they have always been required to maintain for payment.
RCD was scheduled to launch in Illinois in December 2018, but was delayed by six months. RCD finally began in Illinois on June 1, 2019. It expanded to Ohio in August 2019. North Carolina, Florida and Texas will follow in 2020, with the possibility of continued expansion to other states in the Palmetto/JM jurisdiction.
Home health agencies can make their review choice through the Palmetto GBA eServices online provider portal. Agencies that choose pre-claim review will experience a significant administrative burden, but ultimately will have more control over their claims, reimbursement timing and cash flow. It is recommended that those agencies that want to benefit from the cashflow efficiencies of the pre-claim choice work to identify opportunities to automate processes wherever possible.
After a six-month period, HHAs that have reached a target approval rate through pre-claim review or post–payment review will have additional choices, including relief from most reviews except for spot checks to ensure continued compliance.
According to CMS, Illinois HHAs that previously participated in the initial Pre-Claim Review Demonstration for Home Health Services and met the 90% target full provisional affirmation rate (based on a minimum 10 requests submitted from August 2016 through March 2017) can begin the demonstration by selecting from the additional choices.
In Texas, the demonstration is scheduled to begin in March. The choice selection period begins January 15 and ends February 13, 2020, for HHAs in Texas. Agencies that do not make a choice selection by February 13 will automatically be placed in Choice 2: Post-payment Review.
HHAs can visit the Palmetto GBA provider portal here for information and instructions on the selection process. Through the portal, HHAs can view their available choices and make their selection during their choice selection period.
With the arrival of the Patient Driven Groupings Model (PDGM) on January 1, 2020, CMS said it will monitor the transition and assess the need for any delay of the RCD implementation date for Florida and North Carolina.
With the transition to PDGM, CMS said it will phase in the inclusion of Low Utilization Payment Adjustments (LUPAs) within RCD.
For tips on preparing for RCD, check out our eBook, Getting Ready for Review Choice Demonstration.