- Every year, there is considerable home health care fraud in the U.S.
- CMS has rolled out a Home Health (HH) Review Choice Demonstration (RCD) program to help prevent fraud.
- PMB can support your efforts to satisfy the Medicare prior authorization requirements through pre-claim review (PCR) so that you can receive payment for services.
Over the last 10 years, the Department of Justice (DOJ) has recovered more than $2 billion annually from health care fraud. In 2021, home health fraud has been on the rise, including two multi-million-dollar schemes that the DOJ investigated.
Because of the high rate of schemes and fraud in home health care, there is a new Medicare requirement for home health service providers called Home Health (HH) Review Choice Demonstration (RCD).
RCD was initially rolled out in a handful of U.S. states, including Texas, Illinois, Ohio, Florida, and North Carolina. The program will eventually be rolled out across the country as the federal government aims to protect Medicare from funding improper payments, reduce the number of Medicare appeals, and improve compliance with Medicare program requirements.
How Does Review Choice Demonstration (RCD) Work?
The Review Choice Demonstration is a 5-year plan administered by CMS to support authorizations for home health care providers. The demonstration aims to establish a reliable review process that will assist in developing improved procedures to support the following:
- Identify and prevent fraud.
- Protect beneficiaries from harm.
- Safeguard taxpayer dollars.
- Increase care by minimizing unnecessary provider burden.
The demonstration started on June 1, 2019, and is scheduled to end in all states on May 31, 2024. Essentially, the demonstration helps ensure that the right payments are made to the right agencies for the right reasons.
This objective is achieved through a Medicare prior authorization review process or a post-payment review. Within the scope of the RCD program, there are certain requirements that home health care providers must meet before they can start caring for a patient. Home health care providers have three initial review choices to satisfy the requirements:
- Pre-claim Review (PCR).
- Post-payment Review (PPR).
- Minimal review with a 25% payment reduction.
1. Pre-Claim Review
PCR is Medicare’s version of prior authorization. Home health care providers that select this choice should understand that all billing periods will be subject to a pre-claim review. However, providers can make unlimited resubmissions for non-affirmed decisions prior to submitting the final claim for payment.
Also, when performing a pre-claim review request for a beneficiary, CMS may request more than one billing period of care. You will be required to send in advanced orders and receive approval before providing care for the patient.
This is where Precision Medical Billing (PMB) can provide support. Our team of home health experts can provide support managing your Medicare prior authorizations so that you can expedite the review process and start providing care to the patient.
If you currently provide services in one of the roll-out states, then talk to us about a prior authorization solution that fits your agency. Keep in mind that if you do not operate in one of the preliminary roll-out states, the RCD demonstration will eventually reach your state. We can help you prepare now to help smooth out future bumps in the road.
2. Post-Payment Review
The second choice for home health providers is to submit to a post-payment review process that will cover 100% percent of claims. This is the default selection if you do not make an initial review choice.
If you select the choice (or if the choice is made for you), then all of your claims will be reviewed after the final claim submission. Then, once the claim is submitted, you will be asked to complete an Additional Documentation Request (ADR) that will require medical records supporting your claim of services provided.
If you do not respond to the ADR, then an overpayment notification will be issued. This will affect your record. Then, after each six-month period, you will receive notice of your claim approval rate. This rate will affect requirements for future demonstrations.
3. Minimal Review
The third choice is a minimal review that will affect revenue collections. How this works is that 100% of claims will be subject to a 25% reduction in payment. Obviously, the goal is to discourage providers from making this selection so that they will choose to participate in the review.
Also, take note that home health agencies that select this option will remain in this option for the duration of the 5-year demonstration. This is a significant decision that could affect cash flow for the long haul, especially because providers that make this selection may still be subject to a potential Recovery Audit Contractor (RAC) review.
What Happens After the Initial 6-Month Review Period?
Every six months, home health agencies that participate in the pre-claim review or the post-payment review have the option to select a more favorable demonstration — if their approval rate is 90% or greater. This is why your approval rate is important.
The choices in the six-month review period break down as follows:
- Pre-claim Review (e.g. if you want to switch from a post-payment review to pre-claim review).
- Selective Post-payment Review: a random sample of claims will be chosen for review every six months. Note that providers who select this option will remain in this option for the duration of the demonstration.
- Spot Check Review: every six months, 5% of your claims will be randomly selected for review. You can continue with this choice as long as you continue to show compliance with Medicare coverage rules and guidelines.
Work with PMB to Support Your RCD Demonstration
Not sure which review choice to make for your agency? Need help with the Medicare prior authorization if selecting the Pre-claim Review (PCR)? Talk to us about how we can help support your agency.
We understand this is a challenging and unique time for home health care agencies. Whether you are currently subject to the Review Choice Demonstration or if it’s not yet in your state, we can provide you with a solution. We’re ready to provide you with immediate support or help you get out ahead of this future requirement in your state.
Contact us today for a free consultation. Let’s make sure you are prepared for the RCD requirements so that you can collect all payments that you are entitled to receive.