Home Health & Hospice Week

Nearly half of high-performing HHAs didn’t choose smaller-volume review options.

Would you opt for less medical review if you could? If your answer is yes, not all home health agencies feel the same way.

Case in point: The Review Choice Demonstration began in Illinois June 1, as scheduled, a spokesperson for HHH Medicare Administrative Contractor Palmetto GBA confirms. HHAs had a choice of three options for the demo that takes over from the previous Pre-Claim Review demonstration — pre-claim review of 100 percent of claims, postpayment review of 100 percent of claims, or “minimal review” with an automatic 25 percent payment reduction. Then agencies who had a 90 percent or higher affirmation rate under the previous PCR demo had an additional two choices — selective postpay review of a “statistically valid” random sample every six months, or spot check pre-pay review of 5 percent of claims every six months.

Illinois HHAs had until May 16 to make their choice. And what they finally chose may not be what you’d expect. Here’s the breakdown, according to Palmetto GBA:

            Pre-claim review: 51 percent
            Postpayment review: 25 percent
            Minimal review (25 percent penalty): 0 percent
            Selective postpay review: 9 percent
            Spot check pre-pay review: 15 percent

Interesting: About 60 percent of Illinois HHAs were eligible to choose one of the advanced options that would require less claims review, the Palmetto source tells Eli. But only 24 percent of agencies actually opted for selective postpay review or spot check pre-pay review.

Illinois agencies had a variety of reasons for choosing the more comprehensive review option, notes Sara Ratcliffe, executive director of the Illinois HomeCare & Hospice Council. One big one is “if a documentation error is made, you can correct it again and again if need be without penalty” under the 100 percent pre-pay option, Ratcliffe points out.

Other reasons Ratcliffe says providers forewent the smaller-volume options:

• Several providers had not changed their processes when PCR was paused in 2017, so it made sense to stick with PCR.
• With PCR you know up front if you are likely to get paid.
• The amount of documentation needed for PCR is less than what is required for a post payment review.
• PCR has a quicker turnaround from Palmetto than an Additional Development Request (ADR).

Stay tuned: Although the demo launched on time in Illinois, “it’s a little too soon to tell” if the RCD process is running smoothly, Ratcliffe notes. “The next few weeks will let us know.”