RCD and UPICs – Part 2

QIRT Alerts’ April 9th blog posed questions about the relationship between RCD and UPICs. QIRT experts asked: what happens when you have a Review Choice Demonstration (RCD) project and are under the Unified Program Integrity Contractor (UPIC) reviews? And we followed that with many more questions. Since then, “The Review Choice Demonstration HH Team” provided detailed answers.

The “Review Choice Demonstration for Home Health Services Operational Guide,” updated April 3, 2019, top of Page 6, states: “A [home health agency] HHA under Unified Program Integrity Contractor (UPIC) review is not eligible for participation in this demonstration. If an HHA is no longer under review, the HHA will need to select an initial review choice.”


  1. Question: What does “under…review” consist of?  (A UPIC request has been made to the HHA [home health agency] but due date has not yet been reached? The HHA has submitted records to the UPIC but has not yet received the response from the UPIC? The HHA has received a response from the UPIC on records submitted but demand letters have not yet been received from the MAC?) I.e., what are the definitions/parameters for being “under [a UPIC]…review”?
    • Answer: The definition of being under review is a known action being taken by the UPIC for a provider to include pre-pay editing, auto-denial editing, suspension for payment, and other activities that a provider may be subjected during UPIC reviews. Based upon the aforementioned activities the UPIC will alert the MAC once the provider has satisfied the requirements of their activities and now are subject to the demonstration. All activities must be completely satisfied from the UPIC’s view before notification is sent to the MAC to allow a provider to participate in RCD.
  2. Question: For IL agencies otherwise eligible for RCD but in process of a UPIC review: will they have any option make their review selection in Palmetto GBA’s eServices? (within the April 17-May 16 timeline put out by CMS)
    • Answer: All providers will have the option to select a choice regardless of being under UPIC review. If the provider is still under UPIC review at the time of implementation, the UPIC will prevent the provider from participating in RCD until deemed appropriate. If a provider submits documentation for a selected choice, the provider will receive a letter indicating they are not currently eligible for the demonstration. Once released from the UPIC review, a provider will have to wait until the next selection period to be able to participate in RCD. Palmetto will process claims as billed during this period.
  1. Question: Will agencies under UPIC review be notified of this status to allow them to make their RCD choice timely? Or give guidance on why they cannot make a current RCD choice?
    • Answer: AdvanceMed, the UPIC for IL, has sent information to providers who are under their review and not subject to RCD. Once they have completed their actions, AdvanceMed will be sending information to providers to alert them that their UPIC review status has ended and that they should work with Palmetto GBA to determine when they are again subject to RCD.
  1. Question: If an HHA has started RCD (after June 1, 2019) and then receives a UPIC review: will their RCD choice automatically be suspended? (no pre-claim submissions or no ADRs received)
    • Answer: Yes, a provider will be automatically suspended from RCD once a notification is received from the UPIC by the MAC. If a provider submits documentation for a selected choice, the provider will receive a letter indicating that they are not currently eligible for the demonstration.
  1. Related note: To confirm that if the prior PCRD result or all post-payment review options using ADRs: is the approval rate calculated on the claim or the money paid/denied of the ADRs? The guide uses “claim approval” which implies it is based on 90% of claims being fully paid. ADRs and TPE denial rates use a Charge Error Rate/Provider Error Rate of money to calculate further TPE actions.
    • Answer: RCD will be based on a claim rate. TPE does use both claim and payment error rates, however, RCD will look only at 90% or greater claims billed without any error.


So, with only until May 16, 2019, to make the agency selection there is some clarification on how agencies under UPIC review will be handled.

  • From the Palmetto GBA monthly RCD teleconference held on May 1, a few items are also of interest. Nearly every agency has selected Pre-Claim Review (Choice 1) for RCD. Those agencies that did not select Choice 1 were contacted by Palmetto GBA, and nearly all subsequently switched their selection back to pre-claim.
  • On May 3, Palmetto posted a Pre-Claim Review Initial Episode Checklist and a Subsequent Episode Checklist.
  • For Illinois agencies who have been given subsequent review options that choose Statistical Valid Random Sample (SVRS), this will consist of a minimum of 30 claims to undergo review.
  • RCD will apply only to Medicare claims: not Medicare Advantage.
  • For larger agencies, each NPI will have to make a selection. This could vary per agency choice.
  • Agencies undergoing Targeted Probe & Educate (TPE) reviews will have their current probe ended once RCD commences. Note that CERT, UPIC, and RAC activity still continues.
  • The “spot-check” Choice 5 will be handled similar to ADRs. A letter will be issued for the records to be reviewed, that will then be provided and a payment decision made. This will amount to 5% of claims with a minimum of 10 records requested.

More Information

The choice selection period for home health agencies located in Illinois (who have Palmetto GBA as their MAC)  will end on May 16, 2019. Agencies should visit the Palmetto GBA provider portal here for information and instructions on the selection process. While Palmetto GBA has stated it will send letters to all Illinois home health agencies detailing this information, home health agencies do not need to wait to receive their letter. Home health agencies that do not make an initial choice selection by May 16, 2019, will be automatically placed in Choice 2: Postpayment Review. This is not recommended for most agencies.  Illinois agencies eligible for subsequent choices that fail to submit their selection by May 16, 2019, will be automatically be placed in Choice 4: Selective Postpayment Review, and will be locked into that option for the remainder of the RCD project.

Following the close of the choice selection period, the demonstration will begin in Illinois on June 1, 2019, and all episodes of care starting on or after this date will be subject to the requirements of the choice selected.

QIRT is here to help, with two support options:


  • 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.

QIRT Expert Help

  • The outsourcing option – we’ll do it for you.
    • 3 support levels to meet any agency’s needs
    • ContactUs@QIRT.com

Up ↑

%d bloggers like this: