Home Health Review Choice Demonstration

The Review Choice Demonstration (RCD) is a home health review program. It is planned for a 5-year period with initial implementation in Illinois scheduled for June 1, 2019 and expansion into Ohio, North Carolina, Florida and Texas soon after. This program is a continuation of CMS’s efforts to crack down on fraud, waste and abuse of the Medicare benefit in the home health industry.

Isn’t this just Pre-Claim Review all over again?

The Pre-Claim Review Demonstration (PCR) ran from August, 2016 to March, 2017 in Illinois only and was managed by Palmetto GBA. On April 1, 2017, PCR was paused indefinitely for Palmetto GBA (PGBA) to analyze its efficiency and effectiveness and to address some process issues identified in the initial run.

So What Has Changed?

RCD will allow agencies to choose from three initial review options. If an agency can show a 90% or greater success rate for a 6-month period with a 100% submission of at least 10 claims, they can choose a next tier option that may reduce the number of episodes that will be audited. As long as the agency maintains a 90% or higher approval rating with at least 10 requests per six month period, it may stay in the subsequent tier for the remainder of the RCD program.

Once the RCD program is announced, agencies will have a limited time to choose which program they want to participate in. In Illinois, the program was announced on April 3, 2019. Illinois agencies will have from April 17th through May 16th to make their choice through the Palmetto eServices portal. Agencies who do not choose will automatically be assigned to the Post-Payment Review option.

Option 1 – Pre-Claim Review

In the Pre-Claim Review option, the agency submits claim information and scanned .pdf files through the eServices portal to support the medical necessity and homebound status of the beneficiary. This paperwork includes the face-to-face encounter, homecare orders, plan of care, and clinical evaluations among other appropriate documents. Check out the Review Choice Demonstration Handout on PGBA’s website pages 29 through 43 for screenshots of the eServices submission process.

Once documentation is submitted, PGBA will issue a Document Control Number (DCN) to track the progress of the request. After review, PGBA will send a provisional affirmative or non-affirmed decision. If any of the services are non-affirmed, PGBA will provide the reasons. An agency will be allowed to appeal a non-affirmed decision and submit additional documentation in support of that appeal to pursue full provisional approval. The agency will receive a Unique Tracking Number (UTN) for all affirmed HCPCS codes that will be submitted in the treatment authorization code section of the final claim to demonstrate compliance. The UTN will be submitted in positions 19 through 32 of FL63 on the UB-04 or loop 2300 REF02 of the electronic claim appended to the OASIS claim key.

Claims received with a valid UTN for the episode but no UTN on the claim will return to provider with a message about the missing information. If the UTN is non-affirmed, the claim will be denied and may be appealed using traditional appeal options. If the agency is participating in Pre-Claim Review but does not submit for a Pre-Claim Review decision before sending a bill, the claim will be subject to Prepayment Medical Review and, if affirmed, will have a 25% payment reduction penalty that cannot be appealed.

PGBA is required to provide notification of their decision within ten business days of the request for the initial submission or 20 business days for resubmission. If the request is submitted via eServices, the notification will be received through eServices as well. Agencies are not subject to any time constraints except that the affirmed UTN must be submitted on the final claim and RAP auto-cancellation rules will still apply.

A benefit of this method is that as long as there is no evidence of fraud or abuse, agencies will probably not be subject to MAC, RAC or Supplemental Medical Review Contractor audits.

In anticipation of the Patient Driven Groupings Model (PDGM), agencies will be allowed to submit for more than one payment episode at a time.

Option 2 – Postpayment Review

Choosing the Postpayment Review option is voluntarily subjecting your agency to 100% of final claims submissions resulting in an ADR. PGBA will send an ADR immediately upon receipt of the final claim but will process the payment of the claim. The agency will submit all requested documentation within 45 days. PGBA will make a decision within 60 days of receipt. If the agency does not submit the documentation, PGBA will take back the final claim payment.

We can assume that the ADR will process as it does currently. So in addition to the pre-claim review items, agencies will also submit visit and order documents. A denial will result in the final claim payment being recouped and agencies will use the existing appeal process for denials they do not agree with. This could be disruptive to cash flow as level 1 (the MAC) and level 2 (the QIC) can each take about 60 days to reach a decision. Level 3 (the ALJ) is notoriously backed up and projects catching up by 2022.

Option 3 – Minimal Review

For the cost of 25% of each claim you file, you can choose the minimal review option. While claims will not be subject to Probe and Educate reviews, they will be referred to the Recovery Audit Contractor (RAC). Agencies who choose this option are likely putting a target on their backs and opening themselves up to increased scrutiny.

An agency will be required to remain in this option for the duration of the RCD if it is chosen.

Which option should I choose?

It is up to each agency to analyze their volume of Medicare claims and staffing needs to determine what choice is best. Keep in mind that PDGM is coming January 1, 2020. This will increase the number of payment periods and number of Postpayment Review submissions as well as having unknown effects on cash flow potentially making the 25% payment cut under Minimal Review too much to absorb. Therefore, we recommend Option 1 – Pre-Claim Review due to its flexibility and ease of appealing non-affirmed decisions.

Whichever option you choose, remember that RAP auto-cancellation rules will still apply. Agencies who lack the organization to submit timely final claims will have high RAP cancellation rates which will result in RAP payment suppression and all payments received at time of final claim along with other disciplinary procedures.

What are the subsequent options?

If the agency has a greater than 90% success rating for a 6-month period and did not select Option 3, they will be able to choose from three second tier options after performance metrics are tabulated. After evaluation, providers will have a two week window to select their subsequent option. If a provider does not make a choice, they will be automatically assigned to the Selective Postpayment Review option and will not be able to change their option for the remainder of the RCD program.

Option 1 is to start or continue in Pre-Claim Reviews for the next 6-month period. Option 4 is Selected Postpayment Review which would be similar to the Option 2 described above but the number of claims selected for ADRs would be a random sample of at least 30 claims every 6 months. If an agency chooses Option 4, they will not be able to change their choice for the remainder of the RCD. Option 5 is the Subsequent Review option which would spot check 5% of final claims.

While Selected Postpayment Review and Subsequent Review are attractive options due to the lower number of claims to be reviewed, we still think agencies would do better to continue under Pre-Claim Review due to the flexibility, ease of appeals, and potentially less paperwork required.

The good news for Illinois agencies is that those who demonstrated a 90% approval rate of over 10 claims during the PCR in 2016-2017 will be able to choose a second tier option at the start of RCD.

Remember that in each 6-month review period, an agency must have greater than 90% of at least 10 submissions approved to continue in second tier review options or they will have to go back to one of the three initial options. And be cautious about choosing Minimal Review or Selected Postpayment Review since that results in your agency not being allowed to change to another option down the line.

Planned Resources

There are many resources that will be available to agencies during RCD. The Review Choice Lookup will allow an agency to enter their PTAN and NPI number and review their program selection, number of days left in the current review period, who made their choice, and a history of choices made throughout the demonstration period. The Home Health Pre-Claim Review Status Tool will allow entry of patient name, partial MBI and episode dates so that the provider can view UTNs associated with that episode and the HCPCS codes affirmed. If the UTN was non-affirmed, providers can review the education tips provided to assist in crafting a resubmission. CMS is also planning on publishing an Operational Guide and flow chart specifically for RCD.

Current Resources

You can review the CMS RCD website or the Palmetto RCD website for all the current information on Review Choice Demonstration including an Operational Guide. CMS also developed CMS-10599 as part of the Paperwork Reduction Act with additional information about RCD. The 2017 Pre-Claim Review Data for Illinois was recently published and provides the top 15 Non-Affirmation reason descriptions experienced by the agencies during the initial demonstration. This gives valuable insight into the information a reviewer will be looking for under the Pre-Claim Review option of RCD.

Preparing for the Pre-Claim Review option

If you decide on the Pre-Claim Review (PCR) option, now is the time to develop strategies about information and documentation review and submission. Consider creating a form that allows a clinical manager to answer the PCR prompts and then pass it to a clerical person to perform data entry and upload appropriate documentation in eServices. Use the Review Choice Demonstration Handout on PGBA’s website pages 29 through 43 for screenshots of the eServices submission process.

We go over the basics of the original Pre-Claim Review program here, give you some helpful process notes here and talk about submission here. Palmetto has said they will publish a new guide and checklist for the updated program. Keep an eye on our website for an article with details on any changes after it is distributed.

The Wrap-Up

Despite industry objection, the Review Choice Demonstration will be starting in Illinois on June 1, 2017 and will roll out to Ohio, North Carolina, Florida and Texas. It has received OMB approval to go forward. Agencies in these states must keep informed to make the best choice for their patient population and staffing needs. The positive takeaway is that by the end of the initial Pre-Claim Review program, agencies experienced a 95.8% rate of fully affirmed requests. If agencies have continued paperwork processes since the program was paused, there is no reason to believe that success rates will decrease.

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