RCD: The Choices Made

The CMS Review Choice Demonstration (RCD) begins June 1st, and our experts dive into RCD: the choices made during the selection period.

Now that the CMS Review Choice Demonstration (RCD) project has arrived in Illinois, Palmetto GBA posted an item of interest that shows the breakdown of home health agency selections.

Here are the posted results of choices, showing the percentage of agencies making that selection:

  • Option 1: Pre-Claim Review (PCR)  51%
  • Option 2: Post-Payment Review  25%
  • Option 3: Minimal Review  0%
  • Option 4: Selective Postpayment Review  9%
  • Option 5: Spot Check 22% (15% – see update below)

Now, apart from the total percentage from all choices adding up to 107%, these numbers raise contain a few surprises about the choices made by agencies.

1. The reported number of agencies in Option 2.

This option is essentially a 100% post-payment Additional Development Request (ADR) review. All claims will undergo this prior to final payment being made. Historically, ADR reviews have resulted in substantial denials, and with the target threshold of only 10% denial (compared to a Targeted Probe and Educate 20% target from Palmetto GBA), showing compliance will be a tall order. In addition, there will be an increased amount of documentation needed to be sent and a lack of ability to amend the record in case of any administrative or face-to-face encounter issues. These issues add up to further risk for the agencies who selected this choice.

2. There is no breakdown of agency choice selection if subsequent options were available. 

The choice breakdown is for all agencies. Illinois had the added the subsequent options (1, 4, 5) available for agencies who did well under Pre-Claim Review (PCR). Even with these agencies, experts still generally recommended opting for the Pre-Claim Review (Option 1).

3. The Option 4 selection percentage, since agencies are locked into that for the duration of RCD.

Since this choice will be in effect for the duration of the RCD project, selecting this option without establishing a solid compliance pattern is risky.  In addition, since TPE activity ceases when RCD is in effect, should the agency not do well with this option, there is a risk of generating a Unified Program Integrity Contractor (UPIC) review. While less overall claims are reviewed in this option, if the result of the reviews is not favorable, the long-term result may be worse for the agency.

4. Only 51% chose Option 1, pre-claim review.

As the only choice that allows the record to be improved after it has undergone reviews, this should be the go-to choice for most agencies. Knowing that the claim will provisionally pay and removal of possible UPIC activity are great benefits. As well, using this choice will ensure that referral/admission and plan of care generation processes are refined to improve payment probabilities. Every other option poses a higher risk for adverse outcomes from RCD.

5. The fact that 22% of agencies elected the Spot Check option.

While an overall lesser number of claims are subject to review, the content of those claims cannot be improved or amended since final billing has occurred. Remember that the “Spot Check” Choice 5 will be handled similar to ADRs. Palmetto issues a letter for the records to be reviewed. Once the agency provides the required records, a payment decision is made. This will amount to 5% of claims with a minimum of 10 records requested.

Thus the presence of an invalid face-to-face encounter, or a face-to-face encounter that is present but not related to the primary reason for home care, will garner a full denial of service. The Palmetto GBA pre-claim review checklists do list the documents to be considered but offer little regarding the content of what the documents should contain. The spot check option will look at the entire, completed record. However, if any defect is found with orders, signatures, etc. they will not be able to be amended or are amended with great difficulty.

There are a lot of surprises in this data, and the result of the agency choices are soon to become clear. We hope that each agency has made a wise choice.

The RCD start date of June 1, 2019, has arrived. All episodes of care starting on or after this date are 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.
  • The added bonus? Prep for RCD now means an easier transition to PDGM later!

QIRT Expert help

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