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.
CMS announced on October 21, 2019, that it will delay the implementation of the RCD in Texas to March 2, 2020. The RCD is expected to begin in North Carolina and Florida on May 4, 2020. The RCD was originally scheduled to begin in Texas at the beginning of December, right before the implementation date of January 1, 2020, for the Patient-Driven Groupings Model (PDGM).
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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 June 1, 2019, then expanding to Ohio and North Carolina, and later to Texas and Florida. The revised RCD will last five years.
Providers would initially choose between three options:
Choice 1: 100% pre-claim review;
Choice 2: 100% post-payment review; or,
Choice 3: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.
Providers that do not make a choice selection by the end of the 30-day selection period will be automatically placed in "Choice 2: 100% post-rayment review". 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.