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Oklahoma! Where the RCD Comes Sweeping Down the Plains

Although officially the Review Choice Demonstration (RCD) will end next May, it seems that CMS has a few tricks up its sleeve. From the CMS RCD webpage CMS RCD


Update 09/01/2023:


CMS will be implementing the Review Choice Demonstration for Home Health Services in Oklahoma, effective December 1, 2023. CMS has the ability to expand the demonstration to additional states in the JM MAC jurisdiction if there is evidence of fraud, waste, or abuse in those states. Claims analysis showed increased utilization of home health services in Oklahoma, and Oklahoma had higher allowed expenditures and utilization of home health services than the remaining states in the Home Health & Hospice Medicare Administrative Contractor (MAC) Jurisdiction M not already included in the demonstration. To ensure compliance with Medicare home health requirements and protection of the Medicare trust funds. CMS will implement the demonstration according to the following dates:

  • Selection Period Start Date: October 16, 2023

  • Selection Period End Date: November 15, 2023

  • New Selection Effective Date: December 1, 2023

The current version of RCD offers three choices to home health agencies to have their records scrutinized for proper payment and compliance with Medicare eligibility and coverage requirements.


In addition to the 100% pre-claim review option, agencies may also choose a 100% postpayment option—essentially putting themselves on a 100% Additional Development Request (ADR) review—or agencies can opt to not send any claims for pre-claim or postpayment review and suffer an automatic 25% payment reduction.


For determining which choice is best, consider the following on the Initial Options:


Choice 1: Pre-Claim Review

Pro

  • Claim status is known before final billing

  • Affirmed claims are subject to minimal chance of ADR

  • Can use eService, esMD, fax, or paper for submission

  • Items can be amended, added, and obtained since the claim has not yet been final billed

Con

  • 100% of claims undergo review

  • Significant administrative burden

  • Any non-affirmed claim will automatically deny if final billed

  • Can pose an issue getting all record requirements gathered, collated, named, and submitted

  • Need to ensure Unique Tracking Number (UTN) is entered onto claim


Choice 2: Postpayment Review

(Initial Default if no selection made)

Pro

  • Provide service via usual processes: less change to business workflow

Con

  • 100% of claims receive an ADR (Additional Documentation Request) when final billed

  • Review is on postpayment basis: identified as overpayment if denied

  • Significant ADR processing costs: materials, time

  • Difficult to amend the record since it has been billed


Choice 3: Minimal Review with 25% Payment Reduction

Pro

  • No claims are submitted for review

  • No changes to regular business workflow

  • Claims are excluded from MAC Targeted Probe and Educate (TPE) reviews (NOT UPIC audits)

Con

  • 25% payment reduction on all payable claims

  • If selected—cannot change Choice for remainder of RCD

  • The 25% reduction is non-appealable

  • Still subject to possible RAC referral (or UPIC audit)


For the majority of agencies and as demonstrated in the prior states undergoing RCD, Pre-Claim Review (Choice 1) has been the clear consensus selection.


Using Palmetto's eServices, agencies should have made their selection by now, and certainly should not miss the deadline to do so. Palmetto has stressed that agencies can ONLY make their selection via eServices.


The RCD choice selection will apply to claims with any billing period (NOT certification period) on or after December 1, 2023. Palmetto GBA has put out a reminder for agencies selecting Choice 1 (Pre-Claim Review) PGBA PCR Update 10-17-23. This also added a correction to earlier information provided for which claims would subject to this new requirement.


Attention Oklahoma Home Health Providers Who Select Choice 1 (Pre-Claim Review): You Will Begin Submitting PCR Requests on December 1, 2023

Published 10/17/2023

Attention Oklahoma Home Health Providers: Cycle 1 begins on December 1, 2023. If you select Option 1 — Pre-Claim Review (PCR), you may begin submitting your PCR requests for any billing period on or after December 1, 2023. The Unique Tracking Number (UTN) received with the PCR decision must be submitted on every claim with a billing period start date on or after December 1, 2023. If a UTN is not submitted on the claim, the claim will ADR and a 25 percent payment reduction will result. This includes billing periods where the second 30-day period within the 60-day episode of care begins on or after December 1, 2023. For example, if the episode of care began November 17, 2023, the first 30-day billing period would not be included in the Review Choice Demonstration (RCD) because this is prior to the Cycle 1 start date (December 1, 2023). The second billing period in this example begins on or after December 1, 2023; therefore, it is included in the RCD and would require a PCR request. Special Note: Some Oklahoma providers were told that all dates of service will be subject to the review choice demonstration as of December 1, 2023. That information was incorrect, and the above statement will supersede that information.


Oklahoma home health agencies should visit the Palmetto GBA provider portal for information and instructions on the selection process.

In the meantime there are actions to take now to prepare for RCD:


1. Stop for a moment and take a deep breath

2. Read the entirety of the CMS resources:

3. Determine which choice is best for the agency (most will appropriately select Choice 1: Pre-claim review)


4. Look at the agency referral-to-admission process to determine if key information is being obtained so it can be included with pre-claim submissions (or is present in the record in case Choice 1 is not selected). These include the referral, face-to-face encounter documentation, plan of care generation, OASIS assessment completion, and certification documentation.


5. Look at staffing in the agency to match up with the tasks that will be needed for the selected Choice.

6. Review the CMS RCD website and Palmetto GBA site for teleconferences, webinars, and training material.


7. Know the due dates for Choice selection, prepare for implementation, evaluate staffing to meet the needs of record submission, and consider if additional or outsourced assistance is needed.


8. Attend the monthly Palmetto GBA conference call on RCD (first Wednesday of the month, 10 AM Central). While often a rehash of prior information it does offer the chance to ask some questions or keep current on what the MAC wants you to know PGBA RCD Calls


9. Seek outside assistance if needed to ensure you are fully prepared for implementation.

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