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Ten Things To Know About Review Choice Demonstration

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The Centers for Medicare and Medicaid Services (CMS) has confirmed the new start date for implementation of Review Choice Demonstration. Here are ten important things to know about this change affecting home health providers.

  1. Review Choice Demonstration (RCD) will begin for all Medicare-certified home health agencies in Illinois on June 1, 2019. Illinois was the first and only state in which Pre-Claim Review (PCR) was executed between August 2016 and March 2017. PCR was placed on hold due to numerous issues and reintroduced as RCD.
  2. CMS has been planning rollout of RCD since May 30, 2018 as an updated and modified version of the PCR.
  3. The purpose of the RCD is to detect improper payment early and educate the participating agencies on proper documentation of patient eligibility.
  4. Additional states in Palmetto GBA’s jurisdiction after a sixty-day notice of participation. These states will include Ohio, North Carolina, Florida, and Texas, all states in which there is a high number of Medicare beneficiaries.
  5. Beginning with Illinois, each included state must select one of three review choices for claim review:
    1. Pre-Claim Review
    2. Post-Payment Review
    3. Minimal post-payment review with a 25% reduction of final payment.
  6. Agencies in Illinois must enroll in Palmetto’s eServices program between April 17 and May 16, 2019, and select one of the three options for review. If they fail to choose one of these options within this time frame, they will be assigned the default of post-payment review.
  7. All episodes of care beginning June 1, 2019, or after will be subject to the requirements of the review choice the Illinois agency has chosen. However, if this same agency had participated in PCR, and received a 90% target of provisional affirmations during that time, they will have the opportunity to begin the RCD demo with a “spot check” review of a small number of sampled claims.
  8. All agencies in Illinois that achieve a 90% affirmation rate through pre-claim or post-payment review after 6 months will be afforded additional choices for review, including the same spot-check type sample for review.
  9. If the home health agency is under Targeted Probe and Educate (TPE) with Palmetto when RCD is implemented, they will be removed from TPE when RCD begins. Also, claims falling under RCD will be excluded from future TPE reviews; however, the same claims may be chosen as part of Comprehensive Error Rate Testing (CERT), which targets fraud and abuse.
  10. If the agency is under Unified Program Integrity Contractor (UPIC) when RCD begins, they are ineligible for RCD until the UPIC is completed. The agency would also have to decide the type of review they desire when UPIC ceases and PDC begins for them.

The Review Choice Demonstration is tasked with reviewing home health agency documentation for evidence that the beneficiary meets requirements of the home health coverage criteria per Chapter 7 of the Medicare Benefit Policy manual. These requirements include:

  • Confined to the home
  • Under the care of a physician
  • Receiving services under a plan of care established and periodically reviewed by a physician
  • In need of skilled services
  • Having had a face-to-face encounter with an approved provider type that occurred no more than 90 days prior to the home health Start of Care date, or within 30 days of the Start of Care date; is related to the primary reason the person requires home health; and the date of the encounter is documented by the certifying physician.

For more information, look for announcements by Palmetto GBA regarding upcoming webinars. The National Association for Home Care and Hospice (NAHC) recently stated that one such webinar is scheduled to be announced for May 14, 2019.

Axxess is your partner in home health regulation education and solutions. Find more information on our resources webpage, our help center, or request a demo of our solutions today.


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