Review Choice Demonstration

Review Choice Demonstration – What You Should Know

Know the Facts

We have the knowledge and experience from helping agencies in Illinois receive 100% affirmation during the first and only pre-claim review period!

Our Home Health Review Choice Demonstration (RCD) Services ensure the documentation from your home health services are appropriate for payment based on your choice!

• ♦Pre-Claim Review
• ♦Post-Payment Review
• ♦Minimal Post-Payment Review with 25% Reduction
• ♦Selective Post-Payment Review
• ♦Spot Check

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When does Review Choice Demonstration begin?

Coming soon!

Will Review Choice Demonstration expand to other states?

CMS has indicated they plan to roll out RCD to Alabama, Arkansas, Georgia, Kentucky, Indiana, Louisiana, Mississippi, New Mexico, Oklahoma, South Carolina, and Tennessee in the next year or two.

Do agencies in Illinois that reached 90+% affirmation on claims during PCR have to participate?

Illinois home health agencies are NOT exempt from the requirements of Review Choice Demonstration, however, CMS will award credit to those agencies in Illinois that performed well under the Pre-Claim Review Demonstration (PCR). This means that agencies that attained at least 90% affirmation on claims submitted during PCR will be allowed to choose from the following options at the start of RCD:

• ♦Pre-Claim Review of 100% of claims
• ♦Selective post-payment review
• ♦Random spot check review of 5% of claims

What about the agencies in Illinois that didn’t reach 90+% affirmation on claims during PCR?

Illinois agencies that didn’t reach at least 90% affirmation on claims submitted during PCR will be required to choose from one of the “initial” options from the start of RCD:

• ♦Pre-claim review of 100% of claims
• ♦Post-payment review of 100% of claims
• ♦Minimal review with a 25% payment reduction and RAC review

Which Choice is Best?

IHHC frequently hears from providers asking which option is the best choice under RCD. The short answer is that there is not one best choice for all providers—you should consider your business model, payer mix, workflow, staffing levels and claims volume when determining which choice is best for your agency. Here are a few important considerations:

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Illinois providers that did not attain 90% affirmation during PCR will choose from the following “initial” set of options:

1. Pre-claim review on 100% of claims.

• ♦Providers submit a “limited” set of documents through eServices (strongly encouraged), by fax or mail shortly after the start of the episode including the face-to-face clinical encounter note, physician certification, documentation of homebound status, comprehensive assessment and plan of care.
• ♦Providers will not receive ADRs.
• ♦Providers know early in the episode whether claims will likely be paid.
• ♦There is no appeals process for non-affirmations, however, providers have unlimited opportunities to resubmit documentation to get an affirmation and the ability to speak with medical reviewers over the phone to identify missing pieces of information.
• ♦Standard appeals processes apply to the final claim.
• ♦Affirmation rates are calculated every 6 months.
• ♦Once a provider reaches 90% affirmation, they can choose from the “subsequent” set of options.

2. Post-payment review on 100% of claims.

• ♦Providers will receive an additional documentation request (ADR) on 100% of claims after the final claim has been submitted and after payment has been issued.
• ♦Providers will respond to the ADR by sending the patient’s entire chart.
• ♦Standard appeals processes apply.
• ♦Approval rates are calculated every 6 months.
• ♦Once a provider reaches 90% approval, they can choose from the “subsequent” set of options.
• ♦This is the default option for those providers that do not actively make a choice prior to the implementation date of RCD.

3. Minimal review with 25% payment reduction.

• ♦Claims will likely be reviewed by the Recovery Audit Contractor (RAC).
• ♦Providers are stuck in this option for the full five years of RCD and cannot choice a different option.

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Illinois providers that attained 90% affirmation during PCR will choose from the following “subsequent” set of options:

1. Pre-claim review on 100% of claims.

• ♦See considerations above.
• ♦Providers can choose to continue with 100% pre-claim review for the full five years of RCD.

2. Selective post-payment review.

• ♦Palmetto GBA will review a statistically valid random sample of at least 30 claims (potentially more than 30) every 6-months.
• ♦Palmetto GBA will determine the exact number based on claims history.
• ♦Providers will receive an ADR on selected claims after the final claim has been submitted and after payment has been issued.
• ♦Providers will respond to the ADR by sending the patient’s entire chart.
• ♦Standard appeals processes apply.
• ♦This is the default option for those providers that do not actively make a choice prior to the implementation date of RCD.
• ♦Providers are stuck in this option for the full five years of RCD and cannot choice a different option.

3. Spot check of 5% of claims.

• ♦Palmetto GBA will review 5% of the provider’s claims every 6-months.
• ♦Palmetto GBA will determine the exact number based on claims history.
• ♦Providers will receive an ADR on selected claims after the final claim has been submitted, but before payment has been issued.
• ♦Providers will respond to the ADR by sending the patient’s entire chart.
• ♦Standard appeals processes apply.
• ♦Providers can continue in this option unless the spot check indicates the provider is not compliant, in which case the provider must choose from one of the 3 “initial” options.
• ♦Most agencies are seriously considering options 1 and 5. There are pros and cons to each choice that should be considered in the context of your agency’s operations. Take your time, think it through, talk to colleagues within your agency and at other agencies to hear different perspectives.
• ♦CMS has indicated that providers will have 30-days prior to RCD’s start date to make a final selection. Note, you must make your final selection in Palmetto GBA’s eServices portal, whether or not you plan to submit pre-claim requests through eServices. Please log in and re-familiarize yourself with the eServices portalNOW, to ensure you are able to log in without difficulty before the launch of RCD in Illinois.

Details provided by the Illinois Homecare & Hospice Council

CLICK HERE to review CMS’ Review Choice Demonstration Flow Chart!