Home Health & Hospice Week

Stay tuned for operational guide, education.

Gear up now for the Review Choice Demonstration — even if the program isn’t yet scheduled to run in your state.

RCD, which was paused as the Pre-Claim Review program and then re-proposed as RCD in May, is now set to begin in Illinois Dec. 10, the Centers for Medicare & Medicaid Services indicated in a notice published in the Sept. 27 Federal Register (see Eli’s HCW, Vol. XXVII, No. 35).

Some providers are hoping the punishing pre-claim medical review program will once again get halted or called off altogether. But many experts believe it won’t be long before Medicare expands the program to the other four demo states — Ohio, North Carolina, Texas, and Florida — and then even to the other 11 states served by HHH Medicare Administrative Contractor Palmetto GBA.

In the face of heavy industry criticism, CMS is doubling down on its justification for RCD. In its response to comments on the last Office of Management and Budget notice, CMS dismisses the industry’s concerns ranging from access problems to burden-to-benefit ratio to increased hospitalization risks.

“A beneficiary does not have to wait for the pre-claim review request decision to begin receiving home health services,” CMS responds to concerns about access and delayed start dates. “Beneficiaries can then continue to receive those services while the pre-claim review process is in progress.” CMS adds, “home health services will not be delayed and beneficiaries can receive the care and instruction needed for their condition.”

RCD doesn’t add any new documentation requirements, it just checks them for each claim, CMS argues in response to provider burden complaints. “Resources should not need to be diverted from patient care,” the agency says.

In fact, CMS drastically revised downward its cost estimate for the program. While the agency pegged the cost of running the program in the five demo states at nearly $50 million previously, now it says it would cost only $24 million per year.

The big swing is due to the number of participants in the new demo states and the new review choice options available, including the 5 percent spot check (see Eli’s HCW, Vol. XXVII, No. 35 for the demo’s five pre- and postpay options). CMS also significantly changes its expected episodes per beneficiary in Palmetto’s region from 3 to 1.12.

CMS also strikes back at charges that RCD will lead to adverse consequences for patients. “The demonstration will not restrict access to home health services that are medically necessary and meet all the coverage requirements. Discharge from an institution to home will not be delayed, as the same process for initiating home health services … has not changed,” the agency insists. “As home health services for beneficiaries is not being restricted under this demonstration, the beneficiaries will not have additional hospitalization services they would not have normally needed or be pushed into a higher cost care in SNFs or LTCHs. Likewise, the demonstration should not affect work to decrease reliance on opioid medications, ED utilization, or change poor lifestyle choices.”

And CMS disputes commenters’ claims that the program doesn’t actually work to fight fraud and abuse and comes at a steep cost to innocent providers. “By offering several review options and rewarding providers who demonstrate compliance with Medicare home health policies, the demonstration will not unfairly burden providers who are not committing fraudulent behavior or submitting incorrect claims,” it insists.

The previous PCR demo “also had a deterrent effect,” CMS argues. “Knowing that their documentation and claims would be scrutinized, a number of providers did not submit pre-claim review requests during the demonstration, and did not submit claims for payment. When the demonstration was paused, some of these providers submitted claims for payment that had not gone through the pre-claim review process, or that had been non affirmed during pre-claim review.”

CMS made “a number of referrals based on provider behavior during the initial demonstration,” the agency adds.

Because of the 5 percent spot check option for agencies whose RCD requests are affirmed at a 90 percent rate or higher after six months, “CMS does not believe this demonstration will unfairly burden home health providers who are not engaging in fraudulent behavior,” it says. It’s only those “providers who are submitting fraudulent and unnecessary claims [that] will not reach the threshold and will remain subject to review.”

CMS once again trots out the idea that home health is a fraud-riddled industry and needs close monitoring. “Based on previous CMS experience, Office of Inspector General’s reports, Government Accountability Office’s reports, and Medicare Payment Advisory Commission findings, there is extensive evidence of fraud and abuse in the Medicare home health program,” CMS insists in the response. “Data collected from this demonstration will be carefully analyzed” and “used for the purpose of making comparisons between the demonstration and non-demonstration states.”

In other words: Don’t be surprised to see CMS take RCD nationwide after making such a comparison, experts warn.

Demo Details Still Missing

In the meantime, agencies should bone up on the coming demo — especially those in the debut state of Illinois.

There are many questions CMS still needs to answer, notes Sara Ratcliffe with the llinois HomeCare & Hospice Council. For example, HHAs need to find out how they’ll be notified of whether they get to immediately start the 5 percent spot check option based on their PCR performance, as well as the calculation details. “Will CMS take into account the early days of PCR when they weren’t performing as well as in the later days?” Ratcliffe asks.

CMS says it will be holding an Open Door Forum on the demo and issuing an operational guide for the program, and that Palmetto will start conducting education “soon.”

“There are plenty of unknowns still, but hopefully more clarity will come soon,” Ratcliffe tells Eli.

Do this: “Our number one recommendation is that HHAs expand the detail on homebound status and skilled care need in the Plan of Care,” advises National Association for Home Care & Hospice President William Dombi. “Doing so makes it part of the physician record.”

Why is that important? “Medicare looks only at the physician record as a first step in evaluating benefit eligibility,” Dombi tells Eli.

Note: See the notice, which includes instructions on submitting comments by the Oct. 29 deadline, at www.gpo.gov/fdsys/pkg/FR-2018-09-20/pdf/2018-19599.pdf.