No answers yet for Review Choice

Palmetto hasn’t been told when Review Choice will expand or how PDGM will impact the demonstration

Review Choice is officially underway in Illinois this week, but Medicare Administrative contractor Palmetto GBA has no idea when it will expand to Florida, Texas, Ohio and North Carolina, or how 30-day billing cycles will impact the demonstration under Medicare’s new payment model.

The Centers for Medicare and Medicaid Services (CMS) has not shared with Palmetto the planned implementation dates for other targeted states or any plans for integrating the pre-claim review process into the shorter billing framework of the new Patient-Driven Grouping Model (PDGM) which takes effect at the beginning of 2020.

The MAC remains in the dark about both questions, Palmetto representatives told home care providers in a monthly educational call this morning. It was first provider call since the Review Demonstration launched in Illinois this past Saturday, impacting all episodes of care beginning June 1 or later.

“Providers hoping for clarification about implementation dates or how PDGM and Review Choice will work together didn’t get those specific answers today,” said J’non Griffin, owner and president of Home Health Solutions. “But the call did address some other important questions and clear up some confusion.”

June 1 episodes

One of the most confusing aspects of the new Review Choice demonstration has been which episodes are subject to pre-claim reviews: only those with an initial start of care date of June 1 or later, or all episodes beginning on or after June 1, including recertification episodes?

Palmetto representatives clarified in this morning’s call that all episodes beginning June 1 or later – whether they are new episodes, resumption of care episodes or recertification episodes, will be subject to pre-claim review. However, for subsequent episodes of care such as resumption of care or recertification, agencies will not have to submit all previous information dating back to the original start of care.

“What Palmetto actually said was that they are not expecting home care providers to have to go backward for a patient who may have been receiving services in multiple episodes since January,” J’non said. “Only the episodes going forward from June 1 are subject to pre-claim review.”

But there’s a catch. Because Palmetto’s nurse-reviewers looking over the subsequent episodes will be seeing the information for the first time, some documentation from the beginning of the episode will be necessary to bring the nurse-reviewer up to speed, Palmetto representatives said.

As an example, claims for a patient with a Start of Care date from January who has experienced multiple episodes of home care and was just re-certified on May 31 will not be subject to the pre-claim process. The final claim may be submitted as usual with no pre-claim review. However, if the patient with an initial Start of Care date from January was recertified on June 1, the new recertification episode will be subject to pre-claim review and some documentation from earlier episodes will need to be provided to orient the nurse-reviewer.

Two helpful checklists

Providers looking for help to determine the documentation Palmetto requires will find a pair of helpful checklists, one for initial episodes of care and one for subsequent episodes, on the Palmetto web site. The checklists reflect all necessary documentation Palmetto requires for pre-claim review. Access the initial episode checklist by clicking here.

The form for subsequent episodes is available here.

We can help!

Providers in Florida, Texas, Ohio and North Carolina looking to shore up their documentation in preparation for expansion of the Review Choice demonstration may want to check out the Home Health Solutions “Dirty Dozen” digital guide to the 12 most common face-to-face encounter documentation errors, available for $24.99 in The Solutions Shop, our online store. We’ve also put together “Review Choice 101,” a digital guide presenting 101 tips and strategies for creating documentation that passes reviewer scrutiny. We know you're busy, and so is your staff, so it's offered in checklist form, to make it a faster, easier read.