CMS Update: Expansion of Review Choice Demonstration for Home Health Services Set to be Implemented in Oklahoma on December 1, 2023

The Center for Medicaid and Medicare Services (CMS) implemented the Review Choice Demonstration (RCD) with the primary goal of safeguarding Medicare funds from fraud and mis-payments. Through this program, RCD certifies that the beneficiary fulfills the qualifications for home health coverage, ensuring the proper allocation of resources and upholding the integrity of the system.

Currently, RCD is operational in several states, including Texas, Ohio, Illinois, North Carolina, and Florida. Notably, CMS has expanded the RCD implementation to include Oklahoma, effective from December 1, 2023. A thorough analysis of claims revealed a rise in the use of home health services in Oklahoma. The state exhibited higher allowed expenditures and utilization of home health services compared to other states within the Home Health & Hospice Medicare Administrative Contractor (MAC) Jurisdiction M, which were not part of the initial demonstration. Additionally, CMS has the authority to extend the RCD to more states within the JM MAC jurisdiction, provided there is proof of fraud, misuse, and waste of resources in those states.

The Purpose of the Review Choice Demonstration

The RCD ensures correct and timely payments for home health services. It safeguards Medicare funding by preventing improper payments, leading to a reduction in Medicare appeals. Additionally, it enhances provider compliance with Medicare program requirements. The demonstration also includes flexibility for providers and risk-based changes. This alleviates the burden on providers demonstrating compliance with Medicare home health policies.

Home health agencies have three claims submission options to choose from:
Pre-claim review
Post-payment review
Minimal post-payment review with a 25% payment reduction

The benefit of choosing the pre-claim or post-claim review options is that agencies receive an affirmation rate every six months. If the rate is 90% or higher, succeeding review choices will involve a notable reduction in the number of claims examined.

What does the Pre-Claim Review Demonstration Entail?

If home health agencies choose the pre-claim review option for RCD, a provisional affirmation of coverage is submitted for review before the final payment claim. This verifies that the payment, coverage, and coding requirements are adhered to before the final claims are submitted for payment.

Although submitting a pre-claim is optional, neglecting to do so and not receiving confirmation before submitting the final claim leads to a 25% reduction in payment, which cannot be appealed. Therefore, submitting the pre-claim before the final claim is crucial.

How Can Cliniqon Help Home Health Agencies with the Pre-Claim Review Process?

Home healthcare agencies often find that the pre-claim review process adds an additional administrative burden to the already confusing requirements, especially concerning face-to-face encounters. Moreover, pre-claims that are not affirmed can lead to delayed care and interruptions, adversely affecting patient outcomes and experiences. Because of the challenges posed by the pre-claim review process, home healthcare agencies are increasingly seeking efficient solutions to manage their administrative tasks.

One such solution is Cliniqon, an outsourcing company that specializes in the Pre-Claim Review/ RCD Process. Cliniqon currently works with Texas, Florida, and Illinois-based agencies for PCR services, and we are thrilled about assisting organizations in other states as well. As the pre-claim review process is soon to be implemented in Oklahoma, we understand that introducing this new system can be particularly challenging, and we are eager to extend our support to agencies in the state and ensure that they navigate the process with ease. We offer expert assistance and have a team of experienced pre-claim review specialists who handle the entire review process efficiently and accurately. By partnering with Cliniqon, home healthcare agencies can ensure timely submissions, reduced interruptions in patient care, and an enhanced experience for patients and healthcare providers.