There’s been much news recently about the Review Choice Demonstration Project (RCD) in Home Health. In this article, we’ll review the Review Choice Demonstration Project and how it will impact home health agencies in the future.

The Centers for Medicare & Medicaid Services (CMS) implemented a three-year Pre-Claim Review Demonstration for Home Health Services on August 3, 2016 as part of the Paperwork Reduction Act (PRA). The demonstration began in Illinois, with plans to expand the review to Florida, Texas, Michigan, and Massachusetts for a three-year period. The purpose of the demonstration is to make sure that Medicare beneficiaries receive timely, medically necessary care while addressing fraud and reducing improper payments.

As part of the Pre-Claim Review, before the final claim is submitted, a Home Health Agency sends a request for a pre-claim review along with supporting documentation to their Medicare Administrative Contractor (MAC). The MAC then reviews the claim to make sure the patient meets the eligibility and coverage requirements for the home health benefit. Once the review is completed, the agency and the patient will receive a decision by the MAC indicating whether the claim was provisionally affirmed, not affirmed, or partially affirmed and partially non-affirmed. A claim that is provisionally affirmed will be paid as long as all other Medicare requirements are met. The reason for the decision is also included. If the claim is not affirmed, the agency may submit additional documentation to support the claim and a request for another pre-claim review. Agencies may continue to provide care after a non-affirmed claim but cannot bill the patient for denied services unless an Advance Beneficiary Notice (ABN) is given to the patient.

After the first few months of the demonstration, CMS made the decision to focus on more education and to not proceed with implementation of the demonstration to other states beyond Illinois. On April 1, 2017, the Pre-Claim Review Demonstration for Home Health Services was paused in Illinois and not resumed. During the demonstration, approximately 90% of pre-review claims were provisionally affirmed.

Following the pause of the Pre-Claim Review Demonstration, CMS worked to revise the Demonstration to 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 new Demonstration was named the Review Choice Demonstration for Home Health Services.

In the new Demonstration, agencies will be given three options:

  • Pre-claim review of all claims (like the Pre-Claim Review Demonstration)
  • Post-payment review of all claim
  • Minimal post-payment review with a 25% payment reduction

If the agency receives an affirmation rate of 90% or greater after a 6-month period, they may select two additional options:

  • Selective Post-Payment Review
  • Spot Check (5% of claims reviewed)

CMS will implement the Demonstration for Palmetto Medicare Administrative Contractor providers operating in Illinois, Ohio, North Carolina, Florida, and Texas for five years, with the option to expand to other Palmetto states. Through either pre-claim or post-payment review, the Demonstration will help make sure that payments for home health services are appropriate.

The Review Choice Demonstration received approval for implementation on 3/04/2019.

Review Choice Demonstration Project