08/14/2019

Review Choice Demonstration to Begin in Ohio on September 30

The Centers for Medicare & Medicaid (CMS) recently announced that the next state to participate in the Review Choice Demonstration (RCD) is Ohio and it will begin on September 30. In the same announcement, CMS also stated it anticipates 60-90 days between beginning the demonstration in the remaining states of Texas, North Carolina and Florida.

The Review Choice Demonstration is a program which tests pre- or post-claim review for all Medicare home health claims during the span of the demonstration. If a home health agency (HHA) elects to not undergo the heightened payment review, they will continue with the current status quo, but will receive a 25% reduction in payments. 

Medicare certified home health providers in Ohio will have from August 16 - September 15, 2019 to make their RCD choice selection via the Palmetto GBA eServices portal. Selections must be made through eServices so any Ohio providers not already signed up for eServices should do so now using the eServices portal link above.   Ohio HHAs that do not make an RCD choice selection by September 15 will be automatically placed in Choice 2: Post-payment Review.

HHAs will initially select between three review choices:

• Choice 1: Pre-Claim Review,
• Choice 2: Post-payment Review, or
• Choice 3: Minimal review with a 25% payment reduction. (HHAs that select this choice will remain in this choice for the duration of the demonstration regardless of their claim approval rate).

HHAs who do not actively select one of the initial three review choices will be automatically assigned to participate in Choice 2: Post-payment Review. CMS is sending letters to Ohio HHAs detailing this information.

Please note: If a provider has multiple NPIs but with one PTAN – each NPI is to make a RCD selection as each NPI has its own calculated rates.

HHAs who select either Choice 1 or Choice 2 will be evaluated for 6 months. If the HHA’s full affirmation rate or claim approval for those 6 months is 90 percent or greater (based on a minimum of 10 submitted pre-claim review requests or claims), the HHA may select one of the three subsequent review choices:

• Choice 1: Pre-Claim Review,
• Choice 4: Selective Post-payment Review, or
• Choice 5: Spot Check Review.

HHAs that do not actively choose one of the subsequent review options will automatically be assigned to participate in Choice 4: Selective Post-payment Review, and will remain there for the duration of the demonstration.

Ohio providers should note HHAs  under a Targeted Probe & Educate (TPE) review with Palmetto will be removed from the TPE when the RCD begins.  Stakeholders have requested clarification of this from Palmetto several weeks ago as providers could be in various stages of TPE on September 30 (i.e. just beginning Round 3, in the middle of Round 2, etc.). Palmetto had indicated that a provider would need to complete the current TPE round it is in, but also indicated that all TPE would be stopped in RCD states before RCD begins. Providers will not be under both TPE and RCD reviews simultaneously, it is just not clear exactly how this will occur.

Additionally, an HHA under a UPIC (Unified Program Integrity Contractor) is not eligible for the RCD. Any such providers may receive a letter from Palmetto indicating this. When NAHC 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.  Palmetto has indicated that 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). This is somewhat different than what is stated in the CMS RCD HH Operational Guide.  

Claims that are part of the RCD may still be subject to UPIC review if fraud is suspected. Also, claims may be selected as part of the CERT (Comprehensive Error Rate Testing) sample. Again, claims falling under RCD will be excluded from regular MAC TPE reviews.

The National Association for Home Care & Hospice (NAHC) has created an RCD webpage for members that contains valuable information and links to helpful resources.  CMS has published a RCD HH Operational Guide that all providers affected by RCD should review.  There are also several other helpful resources for RCD available from Palmetto.  They are located at the Palmetto GBA Home Health Review Choice Demonstration webpage. (National Association for Home Care & Hospice)