Home Health & Hospice Week

Know your choices.

Unless you underwent Pre-Claim Review in Illinois, you’ll have to undergo at least six months of full blown Review Choice Demonstration medical review when it begins, no matter how stellar your medical review performance.

RCD affects agencies in Illinois, Ohio, North Carolina, Texas, and Florida, with Illinois the only demo state with a set start date (see story, p. 278). However, in its newest Office of Management and Budget notice, the Centers for Medicare & Medicaid Services notes that it may expand the burdensome medical review program to any state served by HHH Medicare Administrative Contractor Palmetto GBA.

In supporting documents for its OMB notice, CMS reviews the three choices it offered in its first description of the RCD, which was slightly revamped from the PCR demo:

Choice 1: Pre-Claim Review. Pre-claim review of 100 percent of claims, with unlimited chances to resubmit the request after non-affirmation. The review is triggered by an agency PCR request. “The MAC will make all reasonable efforts to make and communicate a decision within 10 business days” for initial requests and within 20 days for subsequent requests. “Absent evidence of possible fraud or gaming, claims will not be subjected to postpayment review by a MAC, Recovery Auditor Contractor (RAC), or the Supplemental Medical Review Contractor,” CMS adds. Comprehensive Error Rate Testing and fraud reviews may still apply. Agencies will bill with a unique tracking number (UTN) to pair the claim with the affirmation.

Choice 2: Postpayment Review. The HHA will submit claims as it currently does, which will pay. The MAC will conduct complex medical post-pay review on 100 percent of the claims and will send the agency an Additional Development Request for each claim.

Choice 3: Minimal review with a 25 percent payment reduction. The HHA will submit claims as it currently does and incur a financial penalty that is non-transferrable to the beneficiary and is not subject to appeal. “If a HHA chooses this option, they will remain in this option for the duration of the demonstration and will not have an opportunity to pick a different option later,” CMS emphasizes.

In a demo design explanation, CMS expands on two more choices for HHAs that achieve a 90 percent or greater affirmation rate based on a 10 request/claim minimum:

Choice 4: Selective Postpayment Review. “Claims will pay according to normal claim processes. The MAC will review a statistically valid random sample every 6 months. The MAC will send the HHA an ADR letter for claims being reviewed,” CMS explains. As with minimal review, “the HHA will remain in this option for the remainder of the demonstration and will not have an opportunity to pick a different option later.”

It is unclear just how large the “statistically valid random sample” would be and how it would compare to the volume of reviewed claims under spot check review (below), notes National Association for Home Care & Hospice President William Dombi.

Choice 5: Spot Check Review. The MAC will randomly select 5 percent of claims for prepay review every six months. “The HHA may remain with this choice for the remainder of the demonstration as long as the spot check shows the HHA is compliant with Medicare coverage rules and policy. If the HHA is not in compliance, the HHA must again choose from one of the initial three review options,” CMS says.

Dombi assumes that being out of compliance for Choice 5 means falling below the 90 percent affirmation rate that would allow agencies to opt for this choice in the first place, he tells Eli.

Note: The supporting documentation is at www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing-Items/CMS-10599.html in the ZIP file in the “Downloads” section.