Home Health & Hospice Week

RCD is paused.

The medical world under the novel coronavirus contains many things providers thought they’d never see, including an almost complete respite from medical review.

The Centers for Medicare & Medicaid Services has announced the cessation of almost all types of medical review, starting with the Review Choice Demonstration.“Effective March 29, 2020, certain claims processing for the Review Choice Demonstration (RCD) for Home Health Services will be paused in Illinois, Ohio, and Texas, until the [public health emergency] for the COVID-19 pandemic has ended,” CMS says in a new Frequently Asked Question set.RCD is indefinitely delayed in North Carolina and Florida, where it was scheduled to start on May 4.

How it will work: “Claims for home health services furnished on or after March 29, 2020 and before the end of the PHE for the COVID-19 pandemic in these states will not be subject to the review choices made by the home health agency under the demonstration,” the FAQ says.“However, the MAC will continue to review any pre-claim review requests that have already been submitted.”

HHAs can still submit claims for RCD if they’d like to.“Claims that have received a provisional affirmative pre-claim review decision and are submitted with an affirmed Unique Tracking Number (UTN) will continue to be excluded from future medical review,” CMS offers.

Who should stay the course? “Some organizations — particularly in Illinois where RCD has been in place the longest — may find it more disruptive to re-engineer processes to pause RCD, rather than just continue as-is,” judges reimbursement expert M. Aaron Little with BKD. Plus, continuing with RCD review appears to “prevent the possibility of a post-pay review being conducted once RCD is un-paused,” Little notes.

That’s not exactly certain, however.“Following the end of the PHE for the COVID-19 pandemic, the MAC will conduct postpayment review on claims subject to the demonstration that were submitted and paid during the pause,” the FAQ says. Presumably that excludes claims that already went through PCR. But if not, there’s no reason to continue with RCD during the pause, judges Joe Osentoski with Gateway Home Health Coding & Consulting in Madison Heights, Michigan.

The RCD pause helps HHAs in North Carolina and Florida the most.“For providers in those states to have to manage both the public health emergency and implementation of RCD would be disastrous,” Little expects.

CMS also clarifies that it doesn’t plan to extend RCD past its original end date of May 2024.

Medicare Ditches Other Review Too

It’s not just HHAs under RCD that are benefiting from the review lift.

“CMS has suspended most Medicare Fee-For-Service (FFS) medical review during the emergency period due to the COVID-19 pandemic,” the agency says in the FAQs.“This includes pre-payment medical reviews conducted by Medicare Adminis­trative Contractors (MACs) under the Targeted Probe and Educate program, and postpayment reviews conducted by the MACs, Supplemental Medical Review Contractor (SMRC) reviews and Recovery Audit Contractor (RAC),” the agency says.“No additional documentation requests will be issued for the duration of the PHE for the COVID-19 pandemic.” TPE reviews that are in process will be suspended and claims will be released and paid, CMS says. Current postpay MAC, SMRC, and RAC reviews will be suspended and released from review.

Oversight? “I don’t see Unified Program Integrity activity mentioned,” Osentoski points out.

Perhaps UPIC review falls under an exception CMS carves out for fraud.“CMS may conduct medical reviews during or after the PHE if there is an indication of potential fraud,” the FAQs say.

Watch out: After the PHE ends, “any post-payment review activity could possibly encompass this time of relaxed requirements,” Osentoski cautions. While he’s “not saying they will … nothing at present says they won’t.” Medical review from non-Medicare sources may ease as well. The HHS Office of Inspector General “knows that health care organizations and the dedicated professionals providing care to patients are facing extraordinary challenges in managing the coronavirus pandemic,” says Christi Grimm, Principal Deputy Inspector General.“To the extent possible, we are trying to minimize burdens on providers and be flexible where we can,” Grimm says in a statement issued March 30.

Do this: “Health care organizations that need extensions of OIG deadlines, such as to produce data for an OIG review or to comply with a Corporate Integrity Agreement, are encouraged to ask their OIG contact,” Grimm continues.“OIG will work with organizations on a reasonable solution.”

Industry members wonder whether providers’ and the OIG’s definitions of “reasonable” will match, but the sentiment is encouraging.

“OIG will carefully consider the context and intent of the parties when assessing whether to proceed with any enforcement action,” the OIG adds.

Note: The FAQs are at www.cms.gov/files/document/provider-burden-relief-faqs.pdf.