REVIEW CHOICE DEMONSTRATION

Review Choice Demonstration

As we approach the start of Review Choice Demonstration (RCD) in Ohio on October 1, 2019, we believe providers in all states should be paying attention to the demonstration.  In addition to Ohio, North Carolina, Florida and Texas are included in RCD.  Providers will be given a 60-day notice before RCD starts in their respective state. During this 60-day period providers may choose how they will participate in RCD.

Review Choice, formerly Pre-Claim Review, is Medicare’s response to what they call the “high improper payment rate” in home health.  Medicare’s goal is to reduce the amount of time and money being spent on the “pay and chase” model of reimbursement. Medicare describes RCD as much less restrictive than PCR.  Below are the provider’s options under RCD.

 

  • Choice 1: Pre-claim Review

All episodes of care are subject to pre-claim review.

Unlimited re-submissions are allowed for non-affirmed decision prior to submission of the final claim for payment.

More than one episode of care may be requested on one pre-claim review request for a beneficiary.

Claims associated with a provisionally affirmed request will not undergo further medical review, except in limited circumstances.

  • Choice 2: Post payment Review

100 percent of claims are reviewed after final claim submission.

Default selection if no initial review choice made.

Once the claim is submitted, Palmetto GBA will process the claim for payment then ask via an Additional Documentation Request (ADR) for the HHA to submit medical records. If a response to the ADR is not received, an over payment notification will be issued.

After each six-month period a claim approval rate will be calculated and communicated to the HHA.

  • Choice 3: Minimal review with a 25 percent payment reduction (HHAs remain in this option for the duration of the demonstration)

100 percent of claims have a 25 percent payment reduction. Providers who make this selection will be excluded from regular MAC targeted probe and educate reviews but may be subject to potential Recovery Audit Contractor (RAC) review. Note: Providers who select this option will remain in this option for the 5-year duration of the demonstration.

 

Providers who have chosen options 1 or 2 will work under that option for 6 months.  After 6 months, if a 90% affirmation rate is reached providers may make a subsequent option choice:

  • Pre-claim review- as described above
  • Selective Post-payment review- review of a statistically valid random sample based on the prior 6 months claims
  • Spot check- review of 5% of claims every 6 months

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