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Medical Review Resumption: More Than RCD

This week shows two major actions in relation to medical review of home health records during the Public Health Emergency (PHE).

First was that the suspension of Review Choice Demonstration (RCD) activity due to the current Public Health Emergency (PHE) is about to end.

CMS has posted CMS RCD news that RCD full review activity will resume in the states it is currently implemented (Illinois, Ohio, Texas) and will start in the remaining two states (Florida, North Carolina).

This resumption and addition of RCD is for all activities: pre-claim reviews, post payment reviews, and will also include a catching up on a post payment basis of claims that should have been part of RCD but did not undergo review due to the PHE.

Important dates to keep in mind include the initial choice selection period for North Carolina and Florida, and the second review cycle selection period for Ohio—both to begin on August 3, 2020 and end of August 17, 2020.

Claims with billing periods beginning on or after August 31, 2020 will then be subject to review under the selected RCD option.

Since Illinois, Ohio, and Texas have proved that RCD and PHE can co-exist, CMS has taken notice and the full resumption of RCD is about to happen.

And in case the remaining 45 states feel left out, CMS also has indicated that as of August 3, 2020 that other types of medical review will also resume. FAQ

This means that Medicare Administrative Contractor (MAC) Targeted Probe & Educate (TPE), Recovery Audit Contractor (RAC), Supplemental Medical Review Contractor (SMRC), and Comprehensive Error Rate Testing (CERT) reviews may also resume.

The only allowance of this burden on agencies is that “If selected for review, providers should discuss with their contractor any COVID-19-related hardships they are experiencing that could affect audit response timeliness. CMS notes that 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.”

This will require careful attention that any medical review of claims submitted during the PHE are not judged by non-waiver standards.

So if the pandemic and the PHE were not enough, CMS is turning up the temperature just in time for the peak summer heat.

Joe Osentoski, BAS, RN-BC

ADR and Appeals Specialist

Gateway Home Health Coding & Consulting LLC

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