Via NAHC, WASHINGTON, D.C. (April 3, 2019)—The Centers for Medicare & Medicaid Services (CMS) posted long-awaited information about the next steps for its Review Choice Demonstration, which will begin in Illinois on June 1, 2019.

CMS announced its plans to modify the Pre-Claim Review Demonstration, now called Review Choice Demonstration (RCD), on May 30, 2018. In addition to Illinois, Medicare certified home health providers operating in Ohio, North Carolina, Florida and Texas will be part of the RCD, but CMS has indicated it will provide 60 days’ notice before the Demonstration begins in any of the other four states.

All five of the states chosen for this Demonstration are in the Palmetto GBA Medicare Administrative Contractor (MAC) jurisdiction.

Under the RCD, home health agencies (HHA) will be able to choose one of three review choices:

  • Pre-claim review,
  • Post-payment review, or
  • Minimal post-payment review with a 25 percent payment reduction.

After a six-month period, HHAs demonstrating compliance with Medicare rules through pre-claim review or post-payment review will have additional choices, including relief from most reviews except for a review of a small sample of claims. Illinois HHAs that previously participated in the initial Pre-Claim Review Demonstration for Home Health Services and met the 90% target full provisional affirmation rate (based on a minimum 10 request submitted from August 2016 through March 2017) can begin the demonstration by selecting from the additional choices.

The choice selection period for HHAs located in Illinois will begin on April 17, 2019 and end on May 16, 2019. Providers must be enrolled in Palmetto GBA’s eServices in order to make their selection. HHAs should visit the Palmetto GBA provider portal for information and instructions on the eServices enrollment process (if not already enrolled) as well as the selection process.

Beginning April 17, 2019, HHAs will be able to view their available choices and make their selection through the portal. Palmetto GBA will also send letters to all Illinois HHAs detailing this information; however, HHAs do not need to wait to receive their letter and may go to the provider portal starting on April 17, 2019. HHAs that do not make a choice selection by May 16, 2019 will be automatically placed in Choice 2: Post-payment 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.

Palmetto GBA has indicated that HHAs currently under a Targeted Probe & Educate (TPE) review with Palmetto will be removed from the TPE when the RCD begins in their state. Providers will not be under both reviews simultaneously. Additionally, an HHA under a UPIC (Unified Program Integrity Contractor) is not eligible for the RCD. If the RCD is occurring in their state when the UPIC review is completed, the HHA will need to make an initial RCD choice. This does not mean claims that are part of the RCD will never be reviewed by a UPIC. They may be subject to UPIC review if fraud is suspected. Also, claims may be selected as part of the CERT (Comprehensive Error Rate Testing) sample. Again, claims falling under RCD will be excluded from regular Medicare Administrative Contractor MAC targeted probe and educate reviews.

CMS has published an RCD HH Operational Guide and Palmetto GBA will be holding a RCD webinar on May 14, 2019 at 10:00 AM (information soon to be posted). Palmetto has also indicated that it will be releasing a lot of information, including a checklist of required documentation (similar to what was available under the Pre-Claim Review Demonstration), very soon. NAHC is reviewing the Operational Guide and watching for additional postings and will provide necessary details and more information on the RCD as it becomes available.

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