Home Health & Hospice Week

Industry reps clears up some TPE confusion.

Ohio home health agencies have a big choice to make for the Review Choice Demonstration, and soon HHAs in Florida, Texas, and North Carolina will have to make their RCD selections too.

Like Illinois agencies before them, Ohio providers must choose from these three options for the demonstration program:

Choice 1: Pre-Claim Review. Pre-claim review of 100 percent of claims, with unlimited chances to resubmit the request after non-affirmation. The review is triggered by an agency PCR request. “Absent evidence of possible fraud or gaming, claims will not be subjected to postpayment review by a MAC, Recovery Audit Contractor (RAC), or the Supplemental Medical Review Contractor,” the Centers for Medicare & Medicaid Services adds. Comprehensive Error Rate Testing and fraud reviews may still apply.

Choice 2: Postpayment Review. The HHA will submit claims as it currently does, and those claims will pay. The MAC will conduct complex medical post-pay review on 100 percent of the claims and will send the agency an Additional Development Request for each claim.

Choice 3: Minimal review with a 25 percent payment reduction. The HHA will submit claims as it currently does and incur a financial penalty that is nontransferrable to the beneficiary and is not subject to appeal. “If a HHA chooses this option, they will remain in this option for the duration of the demonstration and will not have an opportunity to pick a different option later,” CMS emphasizes.

Unlike Illinois providers, Ohio HHAs will get a chance to choose these two advanced options only once they’ve established an RCD track record that achieves a 90 percent or greater affirmation rate based on a 10 request/claim minimum over six months.

Choice 4: Selective Postpayment Review. “Claims will pay according to normal claim processes. The MAC will review a statistically valid random sample every 6 months,” CMS explains. As with minimal review, “the HHA will remain in this option for the remainder of the demonstration and will not have an opportunity to pick a different option later.”

Choice 5: Spot Check Review. The MAC will randomly select 5 percent of claims for prepay review every six months. “The HHA may remain with this choice for the remainder of the demonstration as long as the spot check shows the HHA is compliant with Medicare coverage rules and policy. If the HHA is not in compliance, the HHA must again choose from one of the initial three review options,” CMS says.

Even if they get the chance, Ohio agencies may not want to choose the advanced options. About 60 percent of Illinois HHAs were eligible to choose one of the advanced options that would require less claims review back in May, but only 24 percent of agencies actually opted for selective postpay review or spot check pre-pay review, a Palmetto GBA spokesperson told Eli.

That’s likely because HHAs wanted to take advantage of Choice 1 (PCR)’s ability to keep resubmitting claims and correcting errors indefi­nitely (see Eli’s HCW, Vol. XXVIII, No. 20).

The Ohio Council for Home Care and Hospice stresses this option’s benefits in an article on its website. There is “no limit to the number of times the PCR can be resubmitted,” OCHCH’s Beth Foster says. “This means you will eventually receive an affirmation.”

Say Goodbye To TPE — But Not UPIC Review

Good news is that HHAs undergoing RCD review will no longer undergo Targeted Probe & Review edits. “Providers will not be under TPE review and RCD at the same time,” CMS confirms in its RCD Frequently Asked Questions updated last month. “Providers currently on TPE review will be removed prior to CMS implementing RCD in that particular state.”

But the same isn’t true for HHAs under Unified Program Integrity Contractor review. They “are not eligible to make a Review Choice selection and will not participate in the demonstration while under review,” CMS says in the FAQs. “If a provider is removed from UPIC review, the MAC will be notified. The provider will then be informed of their inclusion in RCD and will need to make a review choice selection at the next selection period.”

However: When the National Association for Home Care & Hospice “spoke with Palmetto recently, we learned that even if a provider is undergoing a UPIC review during the Ohio RCD choice selection period of August 16 – September 15, the provider should make an RCD choice,” the trade group says in its member newsletter. “As we understand it from Palmetto, it is only during the RCD choice period when a selection can be made, so if a provider’s UPIC review ends during RCD but after the choice selection period, the provider cannot make a choice until the next choice selection period (every six months),” according to NAHC. Stay tuned for clarification on that point, the trade group recommends.