Ohio: Choose Wisely…

With the countdown to Ohio starting Review Choice Demonstration (RCD) on September 30, 2019 proceeding, Palmetto GBA has posted the first results on home health agency selection. Below, QIRT expert Joe Osentoski breaks it down for us.

For home health agencies in Ohio with Palmetto GBA as their Medicare Administrative Contractor (MAC), the RCD choice selection period began August 16, 2019 and will run to September 15, 2019. During this period agencies should visit the Palmetto GBA provider portal here for information and instructions on the selection process: the Choice selection must be made via the portal.

The Results Are In

Ohio home health agencies that do not make a choice selection by the end of the period will be automatically placed in Choice 2: Postpayment Review (the 100% ADR review). Now, the early results of choice selections made by Ohio agencies are:

  • Choice 1 (100% Pre-claim review): 92%
  • Choice 2 (100% Postpayment review): 8%
  • Choice 3 (Minimal review): 0%

What Do These numbers Really Mean?

Given the pros and cons of each Choice option, it is a surprise that even 8% of agencies chose a 100% postpayment Additional Documentation Request (ADR) review of their records. This is the equivalent of a 100% review of all claims after service has been provided. This involves submitting the entire clinical record to Palmetto GBA for review. Since during this process there is no feedback from Palmetto GBA involved prior to final billing for the claim, this Choice runs a significantly higher risk of denials, generating cash-flow problems and even threatening agency solvency.

The review threshold from RCD for this Choice is that 90% of claims are paid. Note that this is half of the Palmetto GBA threshold for Targeted Probe & Educate compliance (less than 20% denied—80% paid). Agencies under TPE have had tremendous difficulty meeting a 20% denial/80% claim payment threshold—so there is little reason to believe that they will succeed under a 10% denied/90% paid threshold. This is another example of why Choice 1 (100% Pre-Claim Review) is the best choice. And Choice 3 is never an option that makes sense.
Agencies can amend their RCD choice through the end of the selection period. Those 8% that have chosen a 100% ADR option have time to reconsider and change this to the Pre-claim choice. This should be a clear consideration for these agencies as RCD is implemented.


About making the RCD selection, Palmetto GBA has also posted an answer to the question “If I am under a Unified Program Integrity Contractor (UPIC) review, do I need to make an RCD selection?” The guidance (taken from the RCD FAQ) is that all providers should make an RCD selection during the choice selection period. Although providers under UPIC review will not participate in the demonstration while under review, if the UPIC review ends prior to the start date in their state, the review choice selection will become active for the provider at that time. If a provider is removed from UPIC review after the start date for the 6-month review cycle, the provider will make a review choice selection and begin participating in the demonstration in the next cycle. Questions regarding UPIC review should be directed to the UPIC.

What’s Next for Ohio?

Following the close of the choice selection period, the demonstration will begin in Ohio on September 30, 2019, and all episodes of care—NOT just starts of care–starting on or after this date will be subject to the requirements of the choice selected.

Ohio: roughly two weeks remains in the Choice selection period: choose wisely!

QIRT can help.

If you are feeling overwhelmed, reach out for assistance in assessing current status and needs to address before RCD goes live in your state. QIRT experts will help.

1. Do-It-Yourself:

  • Readiness Tool Kit – Prepare for Review Choice Demonstration (RCD) with this advanced tool kit that includes everything an agency needs to complete an RCD Self-Audit: the Agency Guide to Success, plus a survey instrument – the RCD Questionnaire.
  • Analyze your current workflow processes and determine how to adjust for more efficiency and cost-effectiveness. Critical: understand if your current patient charts are complete and contain all the documentation and data required to ensure claims submitted are supported.
  • The added bonus? Prep for RCD now means an easier transition to PDGM later.

2. QIRT Expert Help

More RCD Info

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