Home Health & Hospice Week

Why the late notice?

Your Medicare crystal ball may be cloudy, but you can be pretty sure a Review Choice Demonstration expansion is in there.

On May 17, two weeks before the five-year RCD demo was set to end, the Centers for Medicare & Medicaid Services announced that it is “extending the Review Choice Demonstration for Home Health Services for an additional 5 years. The demonstration will be continuing in the current demonstration states of Illinois, Ohio, Texas, North Carolina, Florida, and Oklahoma,” CMS says on its RCD webpage.

Current Choice 3 providers can select between Pre-Claim Review (Choice 1) or Postpayment Review (Choice 2) to take effect on July 15. Palmetto will open a window from June 17 to July 1 for providers to make their choices. Everyone else will follow their usual cycle timelines in their states.

The extension was a “foregone conclusion,” judges consultant Joe Osentoski with Gateway Home Health Coding & Consulting in Sterling Heights, Mich. Thus, the last-minute notice shouldn’t be disruptive to most, Osentoski tells AAPC.

However: “I was surprised that CMS announced only two weeks before the end of the demo,” notes Mary Carr with the National Association for Home Care & Hospice. “They must have had a sense that it would continue long before,” Carr points out.

CMS has ignored periodic requests from AAPC to address the possibility of the RCD extension over the past year, and Palmetto GBA has likewise failed to offer updates in various question-and-answer sets and other forums. And in the days directly preceding CMS’ May 17 announcement, industry members who inquired about the matter at trade shows also were not told by Medicare officials in attendance, they tell AAPC.

“The last-minute notice is surprising, but it’s not like [CMS has] really bothered with due process in any of this,” observes attorney Robert Markette Jr. with Hall Render in Indianapolis. CMS “announced the original RCD in a Federal Register notice, but there are not regulations, etc.,” Markette tells AAPC.

Nevertheless, “agencies already have processes in place so, for them, it should not be a big problem to continue,” expects consultant J’non Griffin with SimiTree based in Hamden, Conn.

It also strikes Osentoski as “interesting” that CMS is removing Option 3. “If an agency could sustain a 25 percent reduction on payment and still be subject to Unified Program Integrity Contractor and Supplemental Medical Review Contractor activity, why was there a need to remove this choice and push those few agencies into a Pre-claim review or ADR option?” he asks.

CMS may have just been interested in “cleaning up a little-used choice to ‘simplify’ the process,” Osentoski allows.

Do RCD Plus Post-Pay Review Equal Double Jeopardy?

A geographic expansion of RCD looks like a likely next step (see story, p. 139). But CMS needs to iron out some wrinkles first, experts suggest.

Unified Program Integrity Contractor reviews “can look at literally the same charts and issue very high denial rates of previously provisionally affirmed claims,” Osentoski stresses. “If a UPIC denies claims that the MAC prior affirmed, then to me there is an issue of the validity of the pre-claim review — and thus RCD,” he says.

Markette has seen the same, he says. “One provider I worked with was getting their RCD claims approved at 100 percent, but then when the same claims were audited after the fact they were seeing a 100 percent denial,” he says. “That sort of disparity raises some serious questions about the process and is very frustrating for auditors,” he maintains.