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NAHC Asks CMS to Suspend Review Choice Demonstration

Posted on Wednesday, August 1, 2018 6:08 PM

The National Association for Home Health & Hospice  has asked CMS to suspend implementation of the new Review Choice Demonstration (RCD)program because it will be too expensive to implement and there is no proof that it will serve the goals of the program better than the current options available.

RCD targets home health agencies in five states – Illinois, Ohio, North Carolina, Texas and Florida.  Home health agencies in these states will have their claims subjected to a complex medical review on a pre-claim or post-payment basis, or they can choose to take a 25% reduction in the amount paid while still having their claims reviewed by their Recovery Audit Contractor (RAC).

RCD will cost CMS $400 million over five years to administer and the PCRD experience indicates that HHAs will incur significant costs, as well, to submit and manage the exponentially increased paperwork that PCRD/RCD requires. While HHAs strongly support sensible program integrity measures, better alternatives to RCD readily exist.

Based on the lessons of PCRD, the following alternatives would provide preventive, effective and significantly more efficient corrective action:

  1. Revise regulatory standards on physician certification and face-to-face encounter documentation to integrate the physician record with the HHA and other provider records into a single review for a complete, rather than partial record review to establish eligibility.
  2. Develop model document forms to accommodate all elements required for compliance with the face-to-face and physician certification requirements.
  3. Implementation of a documentation certification by the HHAs that would employ a checklist of the documentation required to support a claim, either as an internal process or part of the claim submission process.
  4. Clarified guidance on existing documentation requirements for such as when, where, and how a physician must sign required documentation.
  5. Targeted education directed to both HHAs and physicians using the tools referenced in 1-4 above.
  6. Detailed and specific explanations provided with adverse claim determinations.
  7. MAC education and oversight by CMS specific to documentation standards.

Alternatives to Claim Review

  1. An optional pre-claim review.
  2. Automated review of claims on a prepayment basis using edits related to the billing form and OASIS. The billing form can be modified to incorporate essential eligibility data fields, which in conjunction with an interoperable OASIS review, can demonstrate eligibility.
  3. Random, ongoing application of pre-claim review where a small percentage of RAP submissions trigger the potential for a pre-claim review.
  4. Targeted reviews based on performance, statistical aberrancies, or nature of the claim, e.g., outliers.
  5. Reduced percentage of claims subject to PCR. This approach would bring about efficiencies for all stakeholders while likely achieving comparable effectives with HHAs and MACs learning from the claims subject to review and applying the learning to all claims.
  6. Use of a process like an Independent Review Organization where the HHA selects a compliance organization that does a claims audit and certifies, consistent with CMS-approved standards, that the HHA reached an acceptable level of claim accuracy.

If CMS is determined to implement the RCD as currently constructed, NAHC suggests the following improvements:

  1. A phased-in approach allowing each state undergoing RCD three-to-six months to examine the experiences and lessons of the previous state.
  2. Streamline the documentation process.
  3. RCD should not move forward until there is a full public display of the exemption standards, which are mentioned, but not described in the proposed rule.

Source: NAHC Report


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