Home Health & Hospice Week

Claims review program to hit Oklahoma Dec. 1.

For the first time since 2020, Medicare is imposing the Review Choice Demonstration medical review pilot on a new state — and that may be just the beginning.

History: In response to sky-high Medicare home health payment error rates calculated in the Compre­hensive Error Rate Testing (CERT) program, the Centers for Medicare & Medicaid Services originally planned a Pre-Claim Review demonstration project to begin in Illinois in August 2016 and later roll out to Florida, Texas, Massachusetts, and Michigan. But amid major backlash, PCR was paused in Illinois and called off on the eve of its implementation in Florida in April 2017.

Second try: CMS then re-proposed the project under the RCD name in 2018, swapping out Massachusetts and Michigan for Florida and North Carolina. It re-implemented the retooled program in Illinois in June 2019, then followed with Ohio in September 2019 and Texas in March 2020. Florida and North Carolina were supposed to start RCD in May 2020, but the COVID-19 public health emergency postponed that, with the phase-in period for those two states starting in August 2020 and stretching until September 2021.

RCD has been humming along full throttle in all five states for a year at this point, and now CMS wants to expand it to a sixth state — Oklahoma.

“CMS has the ability to expand the demonstration to additional states in the JM [Medicare Administrative Contractor] jurisdiction if there is evidence of fraud, waste, or abuse in those states,” the agency says on its RCD webpage. “Claims analysis showed increased utilization of home health services in Oklahoma, and Oklahoma had higher allowed expenditures and utilization of home health services than the remaining states in … Jurisdiction M not already included in the demonstration.”

Oklahoma likely won’t be the last state added to RCD. “I do expect RCD to be rolled out to other states within the Palmetto GBA jurisdiction eventually,” says reimbursement expert M. Aaron Little with FORVIS in Springfield, Mo.

“Clearly, CMS is monitoring and analyzing claims data,” Little tells AAPC. “If there are trends in a state’s claims data that demonstrate increased utilization [or] expenditures, then CMS may choose to expand RCD to that state,” he warns.

CMS hasn’t revealed which state — or states — might be next. But they are likely come from the list of states Palmetto serves that aren’t already under RCD: Alabama, Arkansas, Georgia, Kentucky, Louisiana, Mississippi, New Mexico, South Carolina, and Tennessee.

And another expansion is likely to happen quickly, expects Angela Huff, also with FORVIS. “States in that jurisdiction should sit up and take notice of how quickly Oklahoma’s planned addition to this demonstration has occurred,” Huff stresses. “Palmetto agencies should consider how they will quickly adjust if they were to be added to the RCD in the same manner.”

Don’t overlook: Eventually, CMS might take the program nationwide, or at least outside of Palmetto’s service area. CMS seems “ready to move forward with RCD and likely has a plan in place not only for Palmetto, but likely NGS and CGS at some point down the road,” Huff predicts.

For Oklahoma HHAs, “December is going to be here before we know it, which leaves agencies with little time to prepare and adjust to the added expense and operational strain,” says Huff, who notes that Dec. 1 “also coincides with an already busier time of year with the Christmas and winter holidays.” No to mention “this added burden for Oklahoma agencies is also coming at a time when they are trying to focus on [Value-Based Purchasing] as well as the looming potential payment reduction lined out in the proposed rule,” Huff tells AAPC.

Dates: Oklahoma agencies must prepare to enter their RCD review selection between Oct. 16 and Nov. 15.

Note: The Oklahoma RCD announcement is at www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/review-choice-demonstration-home-health-services.