Home Health & Hospice Week

CMS doubles down on pre-claim review.

Don’t be surprised to see Medicare’s 100 percent medical review demonstration program move beyond its original geographic areas — and sooner than you may think.

In a surprise move last summer, the Centers for Medicare & Medicaid Services announced its plan to relaunch the scuttled Pre-Claim Review demo — now known as the Review Choice Demonstration — by Dec. 10, 2018. But CMS bumped that target date when it failed to receive Office of Management and Budget approval for the project.

Now OMB has approved RCD, CMS and HHH Medicare Administrative Contractor Palmetto GBA say in a brief statement posted to their websites. Palmetto will be the MAC that administers the demo.

But as of yet, there are almost no details about RCD’s implementation available. CMS “is finalizing the choice selection process for Home Health Agencies,” it says. (See box, below, to review the five choices HHAs can make.) “Additional information will be available on this website soon.”

While Medicare is keeping silent on the details for now, Illinois agencies can expect CMS to get the program up and running quickly, says attorney Robert Markette Jr. with Hall Render in Indianapolis. “It took some time, but it’s coming,” Markette warns.

And Markette predicts that CMS will roll out the program to other states quickly as well. In a question-and-answer set updated in December, the agency notes that RCD will expand “to Ohio and North Carolina, and later to Texas and Florida.”

If all goes relatively smoothly in Illinois, the expansion will happen quickly, Markette believes.

Expanding to the other demo states isn’t the only growth HHAs need to worry about, Markette adds. CMS has already said it’s ready to expand RCD to other states served by Palmetto GBA, and don’t be surprised to see a proposal for nationwide RCD in next year’s rulemaking cycle, he tells Eli.

Clue: Markette anticipates a quick implemen­tation on a larger scale because CMS seems very committed to the program. The evidence: The Trump administration seemed to heed the industry’s criticisms of the Pre-Claim Review program and halted it on March 31, 2017 (see Eli’s HCW, Vol. XXVI, No. 14). Many in the industry assumed the program was dead for good.

But: Then the administration brought back PCR, as RCD, without any advance warning to the home care community. Why? The statistics on reduced claims and spending were just too appealing to resist, Markette speculates.

Whether it’s for fiscal reasons or really for the fraud-and-abuse-fighting reasons CMS cites, when the agency revisits a concept a second time, you can bet it’s committed to its path, Markette maintains. “This is going to be part of the future of home health,” he predicts.

Industry Ready To Fight Back

CMS’s approbation for the program isn’t the last word, however. “The National Association for Home Care & Hospice (NAHC) disagrees with this strategy for addressing improper payments, particularly in light of the fact that the improper payment rate has significant decreased for home health services,” the trade group says in its member newsletter. The Medicare payment error rate for HHA claims fell from a high of 59 percent for 2015 to a much lower 17.6 percent for 2018 (see Eli’s HCW, Vol. XXVII, No. 42).

“NAHC will continue its advocacy efforts to advance more reasonable approaches that CMS should adopt for ensuring proper payments for home health services,” it vows.

If Medicare’s goal is really to root out fraud and abuse with this program, it should realize that fraudsters often have as good or better documen­tation than legitimate providers, Markette stresses. After all, unlike real HHAs, bogus providers “that aren’t actually seeing patients have time to make their documentation look good,” he points out.

RCD risks access problems in certain areas and for certain kinds of patients, Markette worries. And it will hit HHAs particularly hard during the ramp-up to and implementation of the Patient-Driven Groupings Model, the biggest payment system change since the Prospective Payment System began in 2000, he adds.

Plus: Medicare should really be encouraging home health utilization to prevent pricey hospital­izations as much as possible, Markette says. RCD instead seems to do the opposite. “CMS pays lip service to the idea” of reducing hospitalizations with home health, but the agency’s policies don’t back it up, he criticizes.

Note: Watch for more details on CMS’s RCD page at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Choice-Demonstration/Review-Choice-Demonstration-for-Home-Health-Services.html.