Here’s a detailed look at the options home health providers have under Review Choice
It’s “choose-your-poison month” in Illinois, where home care providers are reviewing their options under Medicare’s new Review Choice Demonstration.
Agencies have until May 16 to decide whether to allow Medicare administrative contractor Palmetto GBA to review all claims before they are submitted for final payment, after they have already been paid, or neither -- which will cause an automatic 25 percent reduction in every payment and still leave the agency subject to Recovery Audit Contractor (RAC) claim reviews.
“For most agencies, none of those three choices is particularly enticing,“ said J’non Griffin, owner and president of Home Health Solutions. “But even though it may feel something like choosing your poison, the choice has to be made by the May 16 deadline.”
The Centers for Medicare and Medicaid Services (CMS) plans to implement its new Review Choice Demonstration for all episodes of care in Illinois beginning on or after June 1. Agencies which do not opt for one of the choices prior to May 16 will automatically be subject to post-payment review of all claims – which could lead to Additional Documentation Requests (ADRs) and notification of overpayment.
All eyes are on Illinois
Home care providers outside Illinois are watching carefully to see which choices are made this month. Interest is especially high in Florida, Ohio, Texas and North Carolina, the four states which have been targeted to go next in the demonstration.
“We still don’t have a firm date for when the demonstration will move into those states,” J’non said. “But CMS has said it will provide at least a 60-day notice before expanding the demonstration to those other states.”
The same format being used in Illinois will be followed when the demonstration moves to other states -- with one exception. Because home care providers in Illinois have already undergone pre-claim reviews as part of a demonstration in that state in 2016-17, agencies which had high claims affirmation rates during the previous demonstration are being offered two less stringent post-payment review options this time.
All home health agencies in Illinois and in other states will be offered at least three initial choices as part of the Review Choice demonstration. After six months of participation, high approval or affirmation rates will enable the agency to choose from two other options.
Here is a closer look at how those choices will work.
The initial choice
In the beginning, home health providers must choose from one of the following three initial choices.
CHOICE 1: Pre-Claim Review
· All episodes of care will be subject to pre-claim review.
· There is no limit to the number of times an agency may re-submit the claim before a final claim is submitted for payment.
· More than one episode of care may be requested on one pre-claim review request for a beneficiary.
· Claims associated with a provisionally affirmed request will not undergo further medical review. CMS notes there may be some limited exceptions to this, however.
CHOICE 2: Post-Payment Review
· 100 percent of claims will be reviewed after the final claim submission.
· Once the claim is submitted, Palmetto GBA will process the claim for payment, then ask via an Additional Documentation Request (ADR) for the agency to submit medical records. If a response to the ADR is not received, an overpayment notification will be issued. After each six-month period, a claim approval rate will be calculated and communicated to the agency.
CHOICE 3: Reimbursement reduction
· 100 percent of claims will have a 25 percent payment reduction on all claims
· Providers who make this selection will not be able to change for the full 5-year duration of the demonstration
· Providers who choose this option will be excluded from regular Targeted Probe and Educate (TPE) reviews, but may be subject to potential Recovery Audit Contractor (RAC) review
Six months later
After six months in the demonstration, the review process could become less stringent for home health agencies which have demonstrated either a high pre-claim affirmation rate or a high post-payment review approval rate. Those agencies will be offered two additional options for post-payment review.
“Agencies will need to have an affirmation or approval rate of 90 percent or greater to be offered subsequent review choices,” J’non said. “If the agency does not meet this standard, it will need to choose again from the initial three choices.”
Agencies will be told by Palmetto at the end of the initial six-month period whether they qualify for subsequent review choices, she said.
These two new subsequent choices will be offered to home health agencies meeting the requirement for at least a 90 percent affirmation or approval rate:
CHOICE 4: Selective Post-Payment Review
· A random sample of claims will be chosen for review every six months
· Default selection if no subsequent review choice is made
· Providers who select this option will remain in this option for the duration of the demonstration
CHOICE 5: Spot Check Review
· Every six months, 5 percent of a provider’s claims will be randomly chosen for review
· Providers will remain in this option as long as they continue to show compliance with Medicare coverage rules and guidelines.
We can help
Palmetto GBA has released a helpful Checklist showing agencies which documentation they will need for Review Choice. Read the article here. Home Health Solutions has a great complementary tool: a detailed list of 101 tips and strategies designed to pass reviewer scrutiny to help agencies shore up their documentation in preparation for Review Choice. This digital guide is presented in a quick-read, checklist format for busy professionals.
“Review Choice 101” is now on sale for $99 in The Solutions Shop, the online store on the Home Health Solutions web site.