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Home Health Review Choice Demonstration: What You Need to Know Now

On November 27, 2018 CMS held a special open door forum to update Home Health Services providers on the soon to begin review choice demonstration. The van Halem Group participated and took notes for you! Here's what you need to know right now.

Who is involved

Home health agencies (HHAs) that operate in and render services to Medicare fee-for-service beneficiaries in Illinois, Ohio, North Carolina, Florida, and Texas AND whom also submit claims to Palmetto GBA, Jurisdiction M MAC. If you provide services to beneficiaries in these states but do not bill claims to JM then you are not part of the demonstration.

When does the Demonstration begin

The demonstration is targeted to start in Illinois no earlier than December 10, 2018, though CMS advised that they will push back the start date, if necessary, to allow for implementation by Palmetto GBA. The demonstration will then be phased into the other states with at least 60 days notice before implementation. The demonstration will last 5 years.

How does the Demonstration work?

HHAs can choose between three initial choices:

·         Choice I:

o    Pre-claim review of all claims

o    Follows process implemented under the initial Pre-Claim Review Demonstration

o    Allows unlimited resubmissions of non-affirmed requests

o    Allows for multiple episodes to be requested on one pre-claim review request for a beneficiary

·         Choice II:

o    Postpayment review of all claims

o    Follows current postpayment medical review processes

o    Default option if no selection made

·         Choice III:

o    Minimal review with payment reduction

o    All home health claims receive a 25% payment reduction

o    Claims are excluded from MAC targeted probe and educate review, but may be selected for Recovery Audit Contractor (RAC) review

Below, more details are provided for each choice.

Choice I: Pre-claim Review

A request for pre-claim review is submitted by either the HHA or the beneficiary and may contain more than one episode, as long as the documenation supports the need for the multiple episodes. The MAC will review the request and supporting documentation and then send a decision letter provisionally affirming or non-affirming the pre-claim review request. A provisional affirmed decision means that the claim will be paid as long as all other Medicare requirements are met.

If a pre-claim review request is non-affirmed, the submitter can resolve the reasons described in the decision letter and resubmit the pre-claim review request. Unlimited resubmissions are allowed prior to submison of the claim. The other option is for the submitter to the claim for denial, which would be afforded appeal rights. During the call, Palmetto GBA did note that the preference would be for HHAs to resubmit after making the necessary corrections.

For choice I decision letters, Palmetto GBA will send the decisions in the same manner the request is received. Pre-claim review requests can be submitted by mail or via the online portal.

Related to the submission of multiple episodes, provisionally affirmed episodes require that a valid plan of care be submitted prior to claim submission. Also of note, a pre-claim review request can be resubmitted for any additional episodes not provisionally affirmed prior to the episode's final claim being submitted for payment.

Initial Requests (first pre-claim review request for any episode) will be reviewed and decisions are to be postmarked within 10 business days. Resubmitted requests (requests submitted with additional documentation following a non-affirmed request) will be reviewed and decisions are to be postmarked within 20 business days.

NOTE: If a HHA choices Choice I (pre-claim review) but does not submit a pre-claim review request before submitting the final claim two things will happen:

1.    The subsequent claim will be stopped for prepayment review

2.    If the claim is determined to be payable, it will be subject to a 25% payment reduction. The reduction is non-transferable to the beneficiary and is not subject to appeal

Choice II: Postpayment Review

If a HHA chooses the postpayment review option (Choice II), the standard processes for intake, service and billing should be followed. The MAC will conduct complex review on the claims during a 6-month interval, by sending Additional Documenation Requests (ADRs) upon receipt of the claim.

HHAs that do not select an intial choice will default to this option.

Choice can be changed after 6 months cycle when Choice I or II is chosen. Choice III must remain in this option for the duration of the demonstration (5 years).

Choice III: Minimal Review with 25% Payment Reduction

If a HHA chooses the postpayment review option (Choice II), the standard processes for intake, service and billing should be followed. HHAs will automatically receive a 25% reduction on all payable home health claims. Any denied claims will retain all normal appeal rights.

HHAs will remain in this option for the duration of the demonstration (5 years) and will not have an opportunity to select a different choice later.

Claims are excluded from MAC targeted probe and educate review, but may be selected for Recovery Audit Contractor (RAC) review

 

Compliance with Pre-Claim and Postpayment Review

In choosing Choices I and II, an affirmation rate/claim approval rate will be calculated every 6 months. If the rate is 90% or greater (based on a 10 request/claim minimum), HHAs can select a subsequent review choice:

·         Pre-Claim review

·         Selective Postpayment review (Choice IV)

·         Spot Check (Choice V)

*Illinois HHAs who participated in the initial PCR demonstration and reached the 90% provisional full affirmation rate (minimum of 10 requests) can start the process with the subsequent review choices.

 

Selective Postpayment review (Choice IV)

If a HHA chooses the subsequent review option - selective postpayment review (Choice IV), the standard processes for intake, service and billing should be followed. After 6 months, the MAC will select a statistically valid random sample (SVRS) for postpayment review, send the HHA an ADR letter and follow standard postpayment review procedures.

Regarding the SVRS, claims will not be subject to extrapolation and will be selected every 6 months.

The HHA will stay in this option for the remainder of the demonstration and will not have an opportunity to select a different review choice later. HHAs that do not select a subsequent choice will default to this option.

Spot Check (Choice V)

If a HHA chooses the subsequent review option - spot check review (Choice V), the standard processes for intake, service and billing should be followed. The MAC will randomly select 5% of the submitted claims for prepayment review every 6 months.

The HHA may remain in this option for the remainder of the demonstration as long as the spot check shows the HHA is compliant with Medicare rules. If the HHA is not in compliance, the HHA must select again from one of the initial three review choices (pre-claim review, postpayment review, or minimal review with 25% reduction).

Per CMS, compliance is determined to be 90% of the 5% reviewed.

Choosing your review option

Once the selection period begins in each state, HHAs will have until two weeks prior to the start of the demonstration to select an initial review choice (pre-claim review, postpayment review, or minimal review with 25% reduction).

HHAs will make the review choice selection through Palmetto GBA's eServices online provider portal: http://www.palmettogba.com/eServices.

Illinois HHAs who participated in the initial PCR demonstration and reached the 90% provisional full affirmation rate (minimum of 10 requests) can start the process with the subsequent review choices.

Other important information

Please note the home health services coverage policies are not changed under the demonstration. Further, the demonstration does not create any new documentation requirements.

HHAs will still be able to submit their Request for Anticipated Payment (RAP) in the same manner as they would without the demonstration being in place.

Also unchanged are the following:

·         All Advanced Beneficiary Notice (ABN) policies

·         Claim appeal rights

·         Dual eligible coverage

·         Private insurance coverage

Access to care and services should not be delayed for people with Medicare's home health benefit.

Please note, during the open door forum, CMS did clarify that claims are excluded from MAC targeted probe and educate review, but may be selected for Recovery Audit Contractor (RAC) review for all Choices, not just Choice III.

Did you know that The van Halem Group has a team of experts on hand to help you navigate through the review demonstration? Whether you would like us to conduct prescreen reviews to ensure your documenation meets coverage criteria or provide education to your billing and intake staff, we are here for you! Contact us today for more information!

 

For more information visit the Review Choice Demonstration website and the Palmetto GBA Jurisdiction M website. Questions should be sent to homehealthRCD@cms.hhs.gov.

 

by Kelly Grahovac – Senior Consultant at The van Halem Group - A Division of VGM Group, Inc. The van Halem Group has become one of the nation's most respected healthcare audit and consulting firms. With over 130 years of related experience, the van Halem Group provides clients the benefit of knowing proper communication channels and processes reducing the regulatory burden. 

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