It’s Alive! The Return of Pre-Claim Review… in the Form of Review Choice Demonstration

After a pause of more than a year, CMS will soon resume the pre-claim review (PCR) demonstration project in five selected states. The pre-claim review is now called Review Choice Demonstration (RCD) for Home Health Services and there are some changes. First of all, tweaks in the new process “offer more flexibility and choice for providers, as well as risk-based changes to reward providers who show compliance with Medicare home health policies.”

The Difference with RCD

In addition to the 100% pre-claim review option of PCR, home care agencies will now be able to choose a 100% post-payment option. Essentially this new option in RCD means putting themselves on a 100% Additional Development Request (ADR) review. As before, agencies can also opt to not send any claims for pre-claim or post-payment review. The result? They suffer an automatic 25% payment reduction.

Notably, other changes to the RCD version of the demonstration are the selected states. All are within Palmetto GBA’s Medicare Administrative Contractor (MAC) Jurisdiction M (JM): Illinois, Florida, Texas, Ohio, and North Carolina. RCD will begin for Illinois as early as December 10, 2018, and the other states will follow suit.

Agencies Most Likely to Feel the Impact of RCD

Agencies weak in quality assurance.

The overall concept of pre-claim review is to stop the “pay and chase” model of claims reviews and shift this to preventing payment for non-eligible services. This will put tremendous pressure on obtaining the initial certification requirements for home health. Now, these requirements include the plan of care, orders for care, and of course the physician face-to-face encounter documentation.

Deficiencies with these items have consistently proven to be among the top denial reasons found in Targeted Probe and Educate (TPE) reviews. Agencies without a strong, consistent, and robust quality assurance asset will be left with significantly impaired cash flow and significant disruption to patient care under RCD. Previous experience with PCR in Illinois showed that most agencies had to devote significant resources to address the process. Consequently, agencies hired staff just to process and track their claims as well as follow-up with referral sources to obtain needed documents.

Minimizing RCD Impact

Looking at the needs of RCD in a top-to-bottom or admission-to-discharge manner is the key to minimizing its impact. Therefore, this disruption to the normal flow of business must be met head-on through process tracking and proper assignment of staff duties. To weather this demonstration project, home health agencies must track processes from:

  1. Receipt of the referral to
  2. Face-to-face encounter documentation to
  3. Plan of care generation to
  4. OASIS assessment completion to
  5. Certification documentation.

QIRT’s RCD Task List

QIRT’s compliance team worked with multiple agencies in Illinois when the Pre-Claim Review (PCR) demonstration began. Based on experience with PCR, agencies will have to hire 1.5 additional FTE (full-time equivalent employee) to administer the required 100% pre-claim submissions. Consequently, our team determined a best practice is to either outsource RCD or outsource coding. To streamline the process, QIRT created an RCD Task List and reporting.

The task list offers a division of labor by splitting tasks between clinical and clerical to ensure timely claim submission and affirmation for billing. It is a template on how to properly bill – efficiently and quickly. QIRT’s RCD Task List Tool requires items to be checked off when completed before allowing for submission. QIRT is also introducing its RCD Team to help relieve pressure from agencies that may suffer from adhering to this new protocol. QIRT’s team is trained to review documentation specific to CMS’ new RCD requirements. This collaboration between agency and QIRT boosts success rates and speeds completion times.

CMS has posted a 30-day Federal Register notice on RCD for comments. After this period has closed on October 29, 2018, they will post responses to the comments received and release additional RCD demonstration details. In the meantime, agencies in the affected states should look at their resources available to cope with this significant new requirement. Coupled with the changes in ICD-10 coding and OASIS, RCD will create a processing bottleneck, but with the proper preparation, your agency can still succeed.

Prepare for RCD

  • Preparation is key.
  • Get out ahead of the changes and alleviate some pressure.
  • Consider outsourcing part of your process.

Just in time for Halloween:

RCD is Alive! But try not to be too scared. Prepare accordingly and partner with the experts at QIRT for assistance.

Questions? Ask our experts:

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