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Medical Review Resumption: More Than Review Choice Demonstration


There have been two major actions recently that both relate to medical review of home health records during the public health emergency. In July, it was announced that the suspension of Review Choice Demonstration (RCD) activity due to the current public health emergency is ending.

Review Choice Resumes

The Centers for Medicare and Medicaid Services (CMS) posted CMS RCD news that RCD full review activity will resume in the states it is currently implemented (Illinois, Ohio, Texas) and will begin in the remaining two states (Florida, North Carolina). This resumption and addition of RCD is for all activities: pre-claim reviews, postpayment reviews. This will also include steps to catch up on postpayment claim reviews that should have been part of RCD but were delayed because of the public health emergency.

The initial selection period for North Carolina and Florida ended on August 17, 2020. The second cycle selection period for Ohio also ended on that date. Claims with billing periods beginning on or after August 31, 2020, will be subject to review under the organization’s selected RCD option.

In addition, RCD Cycle Two for Illinois providers has just been updated due to the COVID-19 pause. Cycle Two began on February 1, and paused after two months. Recently, Palmetto GBA communicated that the remaining four months of the cycle would begin on August 31, 2020 and end on December 31, 2020. After considering additional stakeholder feedback, CMS has now determined that Cycle Two will now end on September 30, 2020. Illinois providers’ RCD Affirmation and Claim Approval rates will be calculated based on review decisions made between February 1, 2020 and September 30, 2020. Palmetto GBA will communicate Cycle Two results to all Illinois providers no later than October 31, 2020.

Since Illinois, Ohio, and Texas have proven that RCD and the public health emergency can co-exist, CMS has taken notice and the full resumption of RCD is going forward.

More Reviews Resume

And in case the remaining 45 states feel left out, CMS also indicated in early August that other types of medical reviews will resume. This means that Medicare Administrative Contractor (MAC) Targeted Probe & Educate (TPE), Recovery Audit Contractor (RAC), Supplemental Medical Review Contractor (SMRC), and Comprehensive Error Rate Testing (CERT) reviews may also resume.

The only allowance of this burden on organizations is that “If selected for review, providers should discuss with their contractor any COVID-19-related hardships they are experiencing that could affect audit response timeliness. CMS notes that all reviews will be conducted in accordance with statutory and regulatory provisions, as well as related billing and coding requirements. Waivers and flexibilities in place at the time of the dates of service of any claims potentially selected for review will also be applied.”

This will require careful attention that non-waiver standards do not judge any medical review of claims submitted during the public health emergency.

So, if the pandemic and the public health emergency were not enough, CMS is turning up the temperature just in time for the peak summer heat.

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