What is Review Choice Demonstration (RCD)?

Overview of the Review Choice Demonstration (RCD)

Purpose and Objectives:

• Ensure Compliance: The RCD ensures that home health services provided to Medicare beneficiaries meet the necessary coverage, documentation, and medical necessity requirements.
• Prevent Fraud and Abuse: By reviewing claims before payment, the program helps prevent fraudulent activities and improper billing practices.
• Enhance Education and Support: The RCD offers education and support to HHAs to help them understand Medicare requirements and improve their compliance with these rules.

2. Demonstration States:

• The RCD is being conducted in five states: Illinois, Ohio, Texas, North Carolina, and Florida. These states were chosen due to historically high rates of improper payments in home health services.

3. Review Options:

• HHAs participating in the RCD can choose from several review options to best fit their operational needs:
• Pre-Claim Review:
  • The HHA submits documentation for review before submitting the final claim. If the documentation meets Medicare requirements, the claim is likely to be paid when submitted.
  • This option helps ensure that the agency meets all requirements before rendering services.
• Postpayment Review:
  • Under this option, the HHA submits claims, and Palmetto GBA reviews them after payment has been made. If any discrepancies are found, payments may be adjusted or recouped.
  • This option might be chosen by agencies confident in their compliance but carries the risk of payment recoupment.
• Minimal Review (25%):
  • After demonstrating high compliance under pre-claim or postpayment review, an agency may qualify for a 25% spot check review option. Only a quarter of their claims will be reviewed.
  • This is a reward for agencies with consistently high compliance rates.
• Selective Review (Targeted Probe and Educate):
  • This option is for agencies with historically low compliance or who fail to maintain compliance under other review options. Palmetto GBA targets specific areas of concern and provides education to improve future submissions.
• Opt-Out Option (100% Penalty):
  • If an HHA chooses not to participate in any of the review options, all their claims will be reviewed post-payment, with a 100% withholding of payments until the review is completed.

4. Process:

• Submission: HHAs submit the necessary documentation depending on the chosen review option. For pre-claim reviews, documentation is submitted before billing; for postpayment, after the claim submission.
• Review: Palmetto GBA reviews the submitted documentation to ensure it meets Medicare’s coverage and billing requirements.
• Decision: Based on the review, Palmetto GBA either approves, denies, or requests additional information. For pre-claim reviews, once approved, the HHA can submit the claim for payment. For postpayment reviews, payment may be recouped if discrepancies are found.

5. Impact on HHAs:

• Improved Compliance: The RCD encourages HHAs to improve their documentation and compliance with Medicare rules, reducing the risk of denials and payment recoupments.
• Operational Adjustments: HHAs may need to adjust their processes to comply with the chosen review option, which could involve additional administrative work or changes in workflow.
• Financial Impact: Depending on the chosen review option, HHAs may face delays in payment or potential recoupment of funds if claims are denied during postpayment reviews.

6. Education and Resources:

• Palmetto GBA provides education and resources to help HHAs understand the RCD process and requirements. This includes webinars, manuals, and direct support to address any questions or issues agencies might have.

The Review Choice Demonstration by Palmetto GBA is a crucial initiative for maintaining the integrity of the Medicare program in the home health sector. It offers HHAs various options to ensure their claims are compliant with Medicare requirements, thus reducing the chances of improper payments and fraud. By participating in the RCD, HHAs can demonstrate their commitment to compliance and quality care, ultimately benefiting both the agency and the patients they serve.