Home Health & Hospice Week

Agencies welcome some clarifications, although heavy burden remains.

Home health agencies are privy to new details of the Review Choice Demonstration as Medicare presses forward with the unpopular medical review program.

In another Office of Management and Budget paperwork notice, the Centers for Medicare & Medicaid Services sets a Dec. 10 implementation date in Illinois for RCD, formerly known as Pre-Claim Review. When RCD was first proposed, CMS said it could go live as early as Oct. 1.

History: The original PCR demonstration began in Illinois in August 2016 and was called off on the eve of its implementation in Florida April 1, 2017. In a surprise move, CMS re-proposed the demonstration under the RCD name in May this year. CMS received about 480 public comments on the RCD notice, during a comment period that closed July 30.

Now, CMS has opened another comment period under an OMB paperwork review notice published in the Sept. 27 Federal Register. In the notice, CMS indicates RCD will begin “no earlier than” Dec. 10 in Illinois. And in OMB supporting documentation, CMS says RCD “will be phased into the other states with at least 60 days’ notice before implementation.”

In a question-and-answer document CMS issued May 31, it noted “CMS will stagger implementation of the Demonstration, beginning with the state of Illinois, then expanding to Ohio and North Carolina, and later to Texas and Florida.” Assuming CMS stays true to that plan and doesn’t propose a new implementation before executing the currently scheduled one, the earliest Ohio and North Carolina would see implementation would be February.

National Association for Home Care & Hospice President William Dombi tells Eli, “We suspect it will be at least 60 days before any other state is added, given CMS’s need to staff up after the dust settles a bit with Illinois.”

To support its newest OMB notice and comment period, CMS has posted a document responding to comments from the last notice; a document summarizing the demo design; and an OMB process supporting statement that, among other things, tabulates the estimated burden of the program.

CMS spends most of the space in the comment response document defending against commenters who said the program was burdensome without having benefits, would cause hospitalization rates to increase, access problems and other adverse consequences, and other criticisms.

For example: “Within this demonstration, the process for providing care remains the same,” CMS maintains in its response. “In addition, the additional review options allow a provider the flexibility to decide which option would work best for their staff and patients. Therefore, CMS does not believe this demonstration would affect the quality of care or limit access.”

Despite CMS’s protestations otherwise, “RCD is still a major administrative burden,” Dombi says. “Much of the burden is in operationalizing the document acquisition, review, and submission process that will be greatly expanded in terms of volume.”

Illinois HomeCare & Hospice Council Executive Director Sara Ratcliffe points out “It’s not simple to implement RCD and there are associated costs and administrative burdens.” While IHHC members are able to “continue the processes that they put in place during PCR so they won’t be reinventing the wheel,” they’ll still see a significant workload increase.

“Is RCD without burden? No,” Ratcliffe tells Eli. “Is Illinois in a better position because of its prior experience? Probably.”

Good PCR Track Record Will Lighten Illinois Agencies’Loads

Among the new details CMS includes, in addition to the December start date, in its OMB paperwork are:

• Spot check threshold. In its initial RCD notice, CMS explained that “once a HHA reaches the target pre-claim review affirmation or post-payment review claim approval rate, it may choose to be relieved from claim reviews, except for a spot check of 5 percent of their claims to ensure continued compliance.” But CMS didn’t include specifics of the “target rate.”

Now, CMS details that “if the provider’s rate is 90 percent or greater (based on a 10 request/claim minimum),” it can qualify for the spot check option. (See more details about that option, story, this page.)

• Illinois history. CMS also clarifies that Illinois agencies could use their track record from the PCR demonstration to qualify for the spot check option.
• Another option. Instead of the prepay spot check option, HHAs with a 90 percent or higher affirmation rate under RCD or PCR can choose the “Selective Postpayment Review” option if they wish.
• Multiple episodes. A pre-claim review request can cover multiple episodes.

CMS may be going full steam ahead on RCD, but the industry still is hoping to delay or even abort the program. “We have congressional support for a pause while CMS answers key questions posed by these members of Congress,” Dombi notes. “Still, we highly recommend that HHAs prepare now as a hedge against RCD implementation.”

Ratcliffe takes a more pragmatic view. “Being realistic, I don’t think that CMS will give a reprieve again or repeal RCD once it starts,” she offers. “My hopes are that CMS will release the information it has on Illinois performance during PCR so that the whole picture is known — our agencies deserve to know. We hope that moving forward CMS will be transparent, fair, and efficient.”

In the meantime, you can submit your comments on RCD by the Oct. 29 deadline.

Note: See the notice at www.gpo.gov/fdsys/pkg/FR-2018-09-27/pdf/2018-20994.pdf.