Home Health & Hospice Week

Reminder: A 90% approval rate gets you on reduced review.

For Illinois home health agencies, the clock is ticking on which Review Choice Demonstration review method they should choose.

But home health agencies in all states should pay close attention to the RCD implementation and rollout, urges attorney Robert Markette Jr. with Hall Render in Indianapolis. That’s because without congressional intervention, the Centers for Medicare & Medicaid Services is likely to expand the claim- and spending-reduction program far and fast (see story, this page).

Under RCD, HHAs have these options for the first six months, CMS notes in supporting documents for its Office of Management and Budget notice:

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. “Absent evidence of possible fraud or gaming, claims will not be subjected to postpayment review by a MAC, Recovery Audit Contractor (RAC), or the Supplemental Medical Review Contractor,” CMS adds. Compre­hensive Error Rate Testing and fraud reviews may still apply.

Choice 2: Postpayment Review. The HHA will submit claims as it currently does, and those claims 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 nontransferrable 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,” 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.”

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.