CMS Announces RCD, Other Reviews Returning

Updated July 15, 2020.

BIRMINGHAM, Alabama (July 9, 2020)–The Review Choice Demonstration program for home health services will resume on August 3, 2020, the Centers for Medicare & Medicaid Services (CMS) has announced.

The program and other medical reviews will move forward no matter the status of the public health emergency, CMS said.

The National Association for Homecare and Hospice (NAHC) expressed concerns about the change of course, especially in Florida and North Carolina, since those states are dealing with surges in COVID-19 cases.

CMS suspended most Medicare fee-for-service medical reviews in March because of the COVID-19 pandemic, including pre-payment medical reviews conducted by Medicare Administrative Contractors (MACs) under the Targeted Probe and Educate (TPE) program and post-payment reviews conducted by the MACs, as well as others.

However, CMS recently announced that, given the importance of medical review activities to the organization’s program integrity efforts and with states reopening, it expects to stop exercising enforcement discretion starting August 3, 2020, regardless of the status of the public health emergency. If selected for review, providers should discuss with their contractor any COVID-19-related hardships they are experiencing that could affect audit response timeliness, NAHC said in a newsletter article on the subject. All reviews will be conducted in accordance with statutory and regulatory provisions as well as related billing and coding requirements. Waivers and flexibilities in place at the time of the dates of service of any claims potentially selected for review will also be applied.

CMS also announced that it plans to resume the Review Choice Demonstration (RCD) beginning August 3, 2020, regardless of the status of the public health emergency. CMS had paused certain claims processing requirements for the RCD for home health services in Illinois, Ohio, and Texas until the end of the public health emergency, and indicated that the demonstration wouldn’t begin in North Carolina and Florida on May 4 as scheduled.

Now, the initial choice selection period will begin for North Carolina and Florida on August 3. The selection period will end on August 17. The choice selection period for Ohio’s second review cycle will also begin August 3 and end on August 17.

Home health claims in all demonstration states (Illinois, Ohio, Texas, North Carolina, and Florida) with billing periods beginning on or after August 31 will be subject to review under the requirements of the choice selected.  This includes pre-claim review, prepayment review, and post-payment review. 

“The restart of the Review Choice Demonstration program fails to take into account that we are at the height of the pandemic with no early end in sight,” NAHC President Bill Dombi said. “Clinical staff need to be providing clinical services, not shuffling paperwork for a demonstration project. We have asked CMS to step back from this action immediately.”

After the demonstration resumes, Palmetto will conduct post-payment review on claims subject to the demonstration that were submitted and paid during the pause. CMS will work with affected providers to develop a schedule for post-payment reviews. Claims that received a provisional affirmative pre-claim review decision and were submitted with an affirmed unique tracking number will continue to be excluded from most future medical review. CMS will share more information on the post-payment review process in the near future. 

Home medical equipment providers will also be subject to the returning TPE program, as well as the reviews from the Recovery Audit Contractor. 

“With COVID-19 cases rising dramatically across the nation, HME suppliers remain fully engaged in treating patients with COVID-19 and  helping reduce the pressure on hospitals and clinicians during this pandemic,” said Tom Ryan, AAHomecare president and CEO. “This isn’t the right time to resume audit activity and ramp up paperwork demands for the HME community.”