On May 31, 2018, the Centers for Medicare & Medicaid Services (CMS) officially announced that they intend to ramp back up the Pre-Claim Review Demonstration (PCR), called the Home Health Review Choice Demonstration (RCD) this time around, with some tweaks and other changes from the original program that only went into effect in Illinois.
HCAF submitted comments to CMS on Friday, August 31, 2018 in response to the proposed policy. Click here to read the comments.
Please direct questions to Kyle Simon, HCAF Director of Government Affairs and Communications, at firstname.lastname@example.org or call (202) 830-4080.
CMS will conduct the revised demonstration in Illinois, Ohio, North Carolina, Florida, and Texas. CMS will stagger implementation of the demonstration, beginning with the state of Illinois on December 10, 2018, then expanding to Ohio and North Carolina, and later to Texas and Florida. Florida home health providers can expect a Summer 2019 start date. The revised demonstration will last five years.
Providers would initially choose between three options:
100% pre-claim review;
100% post-payment review; or,
Minimal post-payment review of a smaller portion of the provider’s home health claims, with a 25% reduction of payment on all home health claims.
If either of the first two options are selected:
Pre-claim or post-payment review will be required for every episode of care.
Providers will continue to be subject to a review method until the home health agency reaches the target affirmation or claim approval rate (90%, based on a minimum of 10 pre-claim requests or claims submitted).
Providers who do not wish to participate in either 100% pre-claim or post payment reviews have the option to furnish home health services and submit the associated claim for payment without undergoing such reviews. However, these providers will receive a 25% payment reduction on all claims submitted for home health services and could be subject to potential Recovery Audit Contractor (RAC) review. Additionally, providers who choose this option will remain under it for the duration of the five-year demonstration and may not select another option.
Once a provider reaches the target pre-claim review affirmation or post-payment review claim approval rate, it may choose to be relieved from claim reviews, except for a spot check of 5% of their claims to ensure continued compliance. The provider may also instead choose to continue or start participating in pre-claim review, or choose to participate in selective post-payment review based on a statistically valid random sample. Until the target rate is reached, review will be required for every home health episode.