Home Health & Hospice Week

Warning: 100% post-pay review waits on the other side of the pause.

In its first response to COVID-19, the feds rushed in with welcome and expansive relief from CARES Act funding to liberalized accel­erated payments to waivers of certain regulatory requirements. But some of that relief isn’t living up to its initial impression.

Case in point: The suspension of Review Choice Demonstration requirements are less expansive than home health agencies may have thought.

Then: “On March 30, 2020, the Centers for Medicare & Medicaid Services (CMS) announced a pause of certain claims processing requirements for the Review Choice Demonstration (RCD) ...in Illinois, Ohio, and Texas until the Public Health Emergency for the COIVD-19 pandemic has ended,” CMS said on its RCD webpage on March 31.“In addition, the demonstration will not begin in North Carolina and Florida on May 4, 2020 as previously scheduled” (see Eli’s HCW, Vol. XXIX, No. 12-13).

CMS went into more detail in a “Coronavirus Disease 2019 (COVID-19) Provider Burden Relief Frequently Asked Questions (FAQs)” posted at that time.“During the pause … 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,” CMS said.“However, the MAC will continue to review any pre-claim review requests that have already been submitted, and providers may continue to submit new pre-claim review requests for review during the pause.”

The FAQ continued, “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.” The statement suggested that if HHAs didn’t use the RCD PCR option, they would undergo typical levels of claim review that agencies in non-RCD states would see afterward, many providers thought.

HHAs in RCD states may not have noticed this statement later in the FAQ: “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.” Or they may not have realized that CMS seems to mean every claim submitted in RCD states will go through post-pay review, if it didn’t go through the usual RCD PCR process during the pause — not just typical review samples.

In an April 13 post on its website, RCD contractor Palmetto GBA seemed more clear. Palmetto told home health agencies that they can “[s]kip the PCR process and submit your claim for payment. The 25 percent reduction will not apply.” However, “Claims paid during the PHE pause will be subject to a postpayment ADR.”

For HHAs under one of the RCD postpay review options, “once the pause is over, any claims that were subject to the demonstration during the demonstration will be reviewed at that time,” Palmetto added.

Bottom line: “All claims that would have been subject to pre-claim review, but were not submitted for pre-claim during the PHE, will receive an ADR at the conclusion of the PHE,” warns Joe Osentoski with Gateway Home Health Coding & Consulting in Madison Heights, Michigan.

This seems to be a gray area, notes reim­bursement expert M. Aaron Little with BKD in Springfield, Missouri. But “in the absence of clar­ifying direction from CMS” it seems that 100 percent post-pay review will apply once the PHE is lifted and RCD is un-paused.

Representatives from Palmetto GBA and CMS did not respond to multiple requests for comment on the RCD pause’s specifics.

What’s The Point?

The 100 percent post-pay review waiting at the end of the RCD pause means “there is really no point to pausing pre-claim reviews,” Osentoski maintains.“It really makes little sense to exchange the known provisional affirmation of a claim for the possibility of denial the future Additional Documen­tation Request (ADR) of a completed claim.”

Consequently, it seems most agencies have carried on with their PCR submission process during the PHE, Osentoski observes.

The pause does offer some relief to providers “whose resources have had to be redirected away from the administrative tasks of RCD due to the PHE,” Little allows.“Also, for those providers in Texas who hadn’t even had time to embrace RCD before the PHE began, I think the pause was welcome relief” — although that relief may end when the 100 percent post-pay review hits.

The big winners of the pause were those HHAs in Florida and North Carolina.CMS has not yet announced a new start date for those states.

Still a chance: Observers hope CMS may see the error of its ways and not impose the harsh 100 percent post-pay standard after all.“I have to believe that if RCD was to remain paused through December 31, 2020 — just as an example — that CMS might decide that due to the volume of claims billed during the pause without a UTN, that only a sample would be subject to post-pay review rather than 100 percent,” Little says. “But this is only speculation,” he qualifies.

Without a definitive statement about the post-pay review ratio, most HHAs have chosen to keep submitting their RCD PCR requests.“It anecdotally sounds like agencies under PCR have continued,” Osentoski says. “Due to the deferred nature of review under RCD, it really makes little sense to stop processing pre-claims and then have to deal with every deferred record being subject to a post-payment ADR when the PHE is over,” he notes.

“We have been advising those agencies who have the resources available to continue the PCR process during the pause to avoid post-pay review once the pause is lifted,” Little tells Eli.

End date: HHAs that have opted to quit submitting their PCR requests, or that signed up for one of the post-pay review options, have little idea of when their RCD review bill will come due.No one is yet hazarding a guess or offering guidance on when the PHE will be declared over, and thus when RCD post-pay review will commence.

Do this: “Agencies have to keep a clear eye out for those PHE waivers that they have used and how they have used them, so that once the PHE is declared over that they resume the pre-PHE CMS requirements,” Osentoski urges. In addition to RCD, that goes for assessments, supervision, teaching/ training, and all the other waiver topics.