Home Health & Hospice Week

When will the medical review program go nationwide — if ever?

If you think the burden of the Review Choice Demonstration will be lifted soon, or might not reach your state at all — think again.

Background: The Centers for Medicare & Medicaid Services pulled its RCD forerunner, the Pre-Claim Review demonstration project, in March 2017 after significant political pressure, such as a letter to CMS from Florida lawmakers including U.S. Sen. Marco Rubio (R), and proposed federal legislation on the matter. The original PCR demo began in Illinois in August 2016 and was set to begin in Florida in April 2017, and then expand to the remaining three states of Texas, Massachusetts, and Michigan.

Then in a surprise move, CMS revived PCR as RCD, swapping out North Carolina and Ohio for Massachusetts and Michigan, and launched it in Illinois in June and Ohio on Sept. 30.

More unexpected developments kept coming. A few weeks ago, CMS announced RCD would begin in Texas in December and Florida and North Carolina in March. Now CMS has delayed that timeline to March and May, respectively (see story, p. 302).

If CMS could listen to logic about the near-simultaneous implementation of the Patient-Driven Groupings Model and RCD, then maybe it will also see clear to give HHAs more breathing room after PDGM implementation before putting them under the intensive medical review demo, providers hope.

Don’t hold your breath: “I think it’s a stretch to think there will be another delay,” expects M. Aaron Little with BKD in Springfield, Missouri.

Further proof of that is CMS Administrator Seema Verma’s Oct. 21 blog post about “The Future of Medicare Program Integrity.” Verma sings the praises of RCD, noting that it is an illustration of “how CMS is working proactively to identify and prevent fraud in an area with high improper payment rates while minimizing unnecessary provider burden.” (Industry members are likely to take issue with her characterization of the demo’s burden.)

The demo “incorporates more flexibility and choice for providers on how their claims are reviewed, as well as risk-based changes to reduce burden on providers demonstrating compliance with Medicare home health policies,” Verma touts.

Verma lays out the Trump administra­tion’s vision of the future. “Program integrity must focus on paying the right amount, to legitimate providers, for covered, reasonable and necessary services provided to eligible beneficiaries while taking aggressive actions to eliminate fraud, waste and abuse,” she says.

Don’t Expect HH’s Lower Payment Error Rate To Save You

There is one scenario that could result in an RCD delay, however. “If it is shown that operating under both PDGM and RCD is not viable for most agencies, then a possible delay (and perhaps a pause in Illinois and Ohio) may occur,” offers Joe Osentoski, reimbursement recovery and appeals director with Quality in Real Time in Sterling Heights, Michigan.

“If PDGM does not go smoothly due to CMS-related issues, then I think [another delay] is possible,” Little allows.

The Texas Association for Home Care & Hospice hopes that “as noted by CMS in their announcement, they will afford Texas the same opportunity for evaluation of the transition as the remaining states,” TAHC’s Rachel Hammon says. In the delay notice, CMS says it “will monitor the transition to PDGM and assess the need for any change to this date.”

If scuttling RCD altogether or even delaying the remaining states is unlikely, then how about the opposite — expanding the program? When CMS revived PCR as RCD, the agency said it retained “the option to expand to other states in the Palmetto/JM jurisdiction” (see Eli’s HCW, Vol. XXVII, No. 22).

Implementing RCD nationwide would fall in line with CMS’s stated goal of reducing improper payments, Osentoski notes. But due to logistical reasons, it’s “more likely that additional states could be added within Palmetto GBA’s Jurisdiction M if the RCD further expands,” he expects.

“The phase-in under the current demo indicates that CMS would have to deal with resource acquisition and implementation to handle increased volume of reviews,” National Association for Home Care & Hospice President William Dombi points out. “Also, the other MACs would need onboarding. Those factors lead me to believe that any near term expansion is not likely.”

Then again: “We are living in a time of bold, sweeping changes in the home health landscape, so I would not preclude an expansion if it shows to CMS significant home health payment reductions,” Osentoski tells Eli.

Remember: Home health spending in Illinois was reduced by $100 million during PCR, with PCR as the only main difference, Dombi has noted in the past.

“I would hate to see [RCD expansion] happen, because it’s a tremendous administrative burden on both the providers and the MACs,” Little says. “I would like to think that CMS and providers could reach a point where something as intensive as RCD isn’t necessary.”

If you hope home health’s sharply declining payment error rate may convince CMS to back off, Verma’s blog post may disappoint you. “Medicare’s improper payment rates have declined but remain too high,” she says.

The home health improper payment rate calculated under the Comprehensive Error Rate Testing program has fallen from a high of 59 percent for fiscal year 2015 claims to 17.6 percent for 2018 claims (see Eli’s HCW, Vol. XXVII, No. 42). CMS is expected to issue 2019 rates in the next month or two.

Note: Verma’s blog post is at www.cms.gov/blog/future-medicare-program-integrity.