RCD: CMS FAQs Add Some Clarity

Last week, CMS updated its Frequently Asked Questions (FAQ) on the pending Review Choice Demonstration (RCD) project. Some of these merit additional scrutiny and comment since the selection window (via Palmetto GBA’s eServices portal) has started for Illinois agencies.

From the “Review Choice Demonstration (RCD) for Home Health Services Frequently Asked Questions (FAQs)”, updated 4/18/19:

Question 20. If I am under a Unified Program Integrity Contractor (UPIC) review, do I need to make an RCD selection?

Answer: Providers under UPIC review are not eligible to make a Review Choice selection. Questions regarding your UPIC review and when you are no longer on UPIC review should be directed to the UPIC.

QIRT Comment: This question was raised since the CMS “Review Choice Demonstration for Home Health Services Operational Guide” indicated that agencies under a UPIC review are not eligible to participate in RCD. Just how a “UPIC review” is defined is apparently up to the UPIC. Any Illinois agencies currently under a UPIC review should not currently be given RCD options, and agencies who have sent ADRs or responded to the UPIC but do not yet have the results may wish to call the UPIC to determine their status.

Question 23. What if a beneficiary only requires a few home health visits? Will the claim still be subject to the demonstration?

Answer: Low-Utilization Payment Adjustment (LUPA) claims with four or fewer visits are excluded from the Review Choice Demonstration for Home Health Services; however, all other episodes that include five or more visits are eligible for review if applicable under the choice selected.

QIRT Comment: A reminder that LUPA episodes do not need to undergo Pre-claim submissions, and should not be subject to the other types of medical reviews or claims reviews.

Question 58. What documents are required for the pre-claim review request?

Answer: The pre-claim review request should include all documents and information that support medical necessity and all eligibility requirements for the beneficiary needing the applicable level of home health services. We do not anticipate the entire record will need to be submitted to support medical necessity (e.g., not every PT note, wound care treatment, etc. may be needed.) The MAC website will provide more specific information for each state.

QIRT Comment: The Palmetto GBA website has a pre-claim submission request form but it is not specific on items to submit. This leaves it more to the determination of the submitter what will meet the requirement. This question does show the major advantage of pre-claim review in that less documents need to be submitted to get that provisional affirmation.

Question 63. Do I need to submit a pre-claim review request before I submit the Request for Anticipated Payment (RAP)?

Answer: Providers are encouraged to submit the Request for Anticipated Payment (RAP) and allow it to process before submitting the pre-claim review request. This will allow the beneficiary record to open on the Common Working File and will ensure you have all of the required documentation to submit with the request.

QIRT Comment: RAP processing and requirements remain unchanged under RCD. Note that CMS recommends that the RAP being submitted prior to the pre-claim submission made for a smoother workflow.

Question 65. If an episode concludes before the MAC has completed pre-claim review, does the HHA need to wait to submit its final claim?

Answer: Yes. The Home Health Agency needs to wait until they receive the pre-claim review decision letter. The decision letter will contain a unique tracking number that will need to be submitted on the claim.

QIRT Comment: Another billing process requirement to keep in mind. Agencies may need to put a “hold” status on claims until any pre-claim activity is concluded. This avoids any chance of submitting a final bill without the UTN and thus eliminates any risk for automatic claim payment reduction. Also remember that if a home health agency has selected Choice 1: Pre-Claim Review and submits a claim without a pre-claim review request being submitted, the MAC will stop the claim for pre-payment review. If the claim is payable, it will be paid with a 25% reduction of the full claim amount. The UTN that prevents this is given with the response to the pre-claim review submission.

Question 88. What documents are required for the review choices other than pre-claim review?

Answer: The HHA should submit all documentation and information that are currently required for medical review of home health claims. The documentation should support the eligibility and need for the level of services indicated on the claim.

QIRT Comment: “Medical review” = Additional Development Requests. This is essentially the entire record. Pre-claim submits much less content for review – another advantage of selecting Choice 1.

Question 97. What should Home Health Agencies do if the certifying physician will not provide documentation?

Answer: If the physician and/or facility will not provide the documentation, Home Health Agencies should notify their MAC or CMS (at HomeHealthRCD@cms.hhs.gov) of the uncooperative physicians and/or facilities. Physicians and/or facilities who show patterns of non-compliance with this requirement, including those physicians and/or facilities whose records are inadequate or incomplete, may be subject to increased reviews, such as through provider specific probe reviews.

QIRT Comment: This is a new item, and we shall see if agencies choose this approach to improve physician assistance for agency needs. Physician face-to-face encounter issues remain a top home health denial reason for all medical reviews and since now all claims will undergo some form of scrutiny under RCD, it will most likely take on an even larger significance.

Question 100. Do we need to submit the face-to-face (F2F) encounter documentation for each benefit period if we already submitted it with a previous Pre-Claim Review (PCR) request and it was approved for the beneficiary?

Answer: Yes, if the PCR request is for a new episode of care, the HHA must submit all certification documentation as well as recertification documentation as each episode is reviewed independently.

QIRT Comment: A reminder that recertification episodes must include certification requirements from the initial episode. Thus a bad face-to-face encounter or certification defect will cause ongoing claim issues.

Question 101. When does the Plan of Care (POC) need to be signed when submitting PreClaim Review for additional episodes?

Answer: The POC needs to be signed prior to submitting a Pre-Claim Review (PCR) request. Timeliness of Signature Requirements can be found in the Medicare Benefit Policy Manual Publication 100- 02, Ch 7, Section 30.2.4.

QIRT Comment: Pre-claim submission cannot be made until the plan of care is signed.  This is different than the RAP requirement. This may result in another agency process change to ensure that this is completed prior to submitting the claim. Note: Therapy plans of care that are signed by the physician and contain orders and treatments may also need to be signed before submitting the pre-claim review, or else the plan of care will be incomplete when being evaluated. Other verbal orders for changes in treatment may also be submitted since they are part of the plan of care, although it is less clear that all orders that have been verbally obtained at the time of submission need to be signed.

What else to remember?

Finally, a reminder that the choice selection period for home health agencies located in Illinois (who have Palmetto GBA as their MAC) has begun on April 17, 2019, and will end on May 16, 2019.  These agencies should visit the Palmetto GBA provider portal here for information and instructions on the selection process.  As of April 17, 2019, home health agencies are able to view their available choices and make their selection through the portal.  Palmetto GBA will also send letters to all Illinois home health agencies detailing this information.  However, home health agencies do not need to wait to receive their letter.  Home health agencies that do not make a choice selection by May 16, 2019, will be automatically placed in Choice 2: Postpayment Review. 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.
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  • The added bonus? Prep for RCD now means an easier transition to PDGM later!

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  • The outsourcing option – we’ll do it for you. ContactUs@QIRT.com

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