Joe Osentoski, BAS, RN-BC
ADR and Appeals Specialist
Gateway Home Health Coding & Consulting LLC
Due to the current Public Health Emergency (PHE), CMS and Medicare Administrative Contractor Jurisdiction M Palmetto GBA have set out some significant changes to current Review Choice Demonstration (RCD) activity. Here’s a quick look at what’s going on. CMS RCD
First, the start of RCD in North Carolina and Florida that was scheduled for May 4, 2020 has been paused. Note, however, that the Selection Period for both these states is currently open through April 19, 2020. Agencies in these states should make their selection through Palmetto GBA eServices to avoid being placed in Review Choice 2: the 100% Postpayment review via Additional Development Request (ADR).
Second, the initial six-month period of review in Ohio ended on March 31, 2020. Palmetto GBA is still considering how this will affect determining the agency affirmation/claim approval rate. In the mean time, it is recommended that Ohio agencies continue to process their claims under the prior RCD guidance based on their initial selection (but see below).
Third, Texas and Illinois agencies (and also includes Ohio—who are in a different timeline of their review periods) have a choice on how to proceed with their claims. This is because officially, the Review Choice Demonstration is “paused.”
This means that for claims FINAL BILLED on or after March 29, 2020—and before the [currently undefined] end of the PHE, that there is no MAC initiated medical review activity. For any of the Review Choices using ADRs (2, 4, 5), no new ADRs will be issued. Any claims that have had ADRs without a result issued will be release and paid without further review. These will also not be subject to later review.
For agencies under Pre-Claim Review Choice 1, the main decision will be whether to continue to submit claims for pre-claim review or not. This leads to a variety of possible outcomes:
Submit the claim for pre-claim review per usual procedure, obtain a UTN, if the claim is fully provisionally affirmed submit the final bill with that UTN and it will pay.
Submit the claim for pre-claim review, obtain a UTN, if a fully affirmed provisional affirmation is not obtained, submit the final bill with the UTN, the claim will deny, and the agency can then appeal the denial. Note that if the provider has a non-affirmed UTN and submits a claim without the UTN, it will not process for payment without a 25 percent reduction, but will instead Return to Provider (i.e., if the UTN is left off the final claim, it will RTP).
Choose NOT to submit a claim for pre-claim review, even if under Review Choice 1, submit the final bill without a UTN (as the claim was not submitted for review), and the claim will then be paid without the automatic 25% payment reduction that would have normally occurred. KEEP IN MIND that this will result in every claim that was not submitted for pre-claim review being subject to a postpayment ADR once the PHE ends.
This all adds up to a significant amount of ADRs being backlogged once the PHE ends, when all claims that would have been part of the RCD will still undergo some form of MAC activity (unless prior pre-claim affirmed).
Thus, not-submitting claims for pre-claim review simply shifts the current payment on the claim for a later ADR review of that claim.
Some other areas that may affect continuing pre-claim reviews include the loosening of the homebound definition; the ability of NPPs to refer to home care, complete face-to-face encounters, and sign physician orders (if allowed by that state); and acceptance of telehealth visits conducted via telephone or video for completion of required encounters.
PGBA has posted on their website the preliminary agency choice selections for North Carolina and Florida. Virtually all agencies who have made their selections opted for Choice 1 Pre-Claim Review. This is to be expected given the deficits of the other Initial Options.
It is an agency choice on whether to continue pre-claim review submissions during the PHE. Palmetto GBA has stated they will continue to review claims during this time—only the ADR options will otherwise be affected. Remember that Patient-Driven Groupings Model (PDGM) is not changed by the PHE, don’t forget that as of April 2, 2020 that Low Utilization Payment Adjustment (LUPA) claims are required to be included in the Pre-Claim submissions, and that the adjustments to RCD applies to claims final BILLED (not dates of service) on/after March 29, 2020.
This is also most likely not the end to RCD adjustments during this period as many of the requirements, rules, and regulations of compliance are relaxed or amended.