Home Health & Hospice Week

But review schedule will consider burden, CMS says.

Home health agencies hoping for a reprieve on an onerous postpayment review standard when the Review Choice Demonstration ends will be disappointed by the latest comments from Medicare and MAC officials.

Problem: When the Centers for Medicare & Medicaid Services announced the “pause” for RCD in late March, in conjunction with its halt of most kinds of medical review, ambiguous language led some agencies to hope that postpayment review of claims after RCD was un-paused would be limited (see Eli’s HCW, Vol. XXIX, No. 21).Affected claims are those that would have undergone pre-claim review under usual RCD.

Unfortunately, the answer of whether postpay review of those claims will be limited now appears to be a definite “no.”

“One hundred percent of all claims that should have gone through the pre-claim review process, but did not because of the pause, will be reviewed,” a CMS spokesperson confirms to Eli.

“Following the end of the pause, [RCD contractor] Palmetto GBA will conduct postpayment review on all claims subject to the demonstration that were submitted and paid during the pause,” agrees a Palmetto spokesperson.

Industry experts have expressed hope that if the PHE goes in for a long time, perhaps CMS would relent on the total postpay review due to sheer review volume. But the agency isn’t ready to concede that point. Instead, “CMS will work with providers to ensure the post payment reviews happen on a schedule that does not increase provider burden,” the spokesperson offers.

HHAs in Illinois, Ohio, and Texas that kept up with their PCR submissions won’t be affected by postpay review.“Those claims that were submitted with an affirmed Unique Tracking Number (UTN) or would not have normally been subjected to review under the RCD guidelines will not be reviewed under postpayment review,” the Palmetto rep explains.

“This is not great news, but not unex­pected, either,” allows M. Aaron Little with BKD in Springfield, Missouri.“Agencies that have the resources available to them to continue to follow the PCR process during the pause should continue to do so to avoid postpay review. At least with PCR there is an opportunity to fix documentation issues resulting in non-affirmed claims.”

Joe Osentoski with Gateway Home Health Coding & Consulting urges agencies to “resume PCR unless you wish to get a large number of postpayment ADRs.Swapping no reviews now for ADRs later makes no sense if your original choice was PCR and you wanted to take the advantage of PCR over the risks of ADRs.”