CMS Stands by Pre-Claim Review Revival, Provides Additional Information

The U.S. Centers for Medicare & Medicaid Services (CMS) is standing firm on its home health Review Choice Demonstration (RCD) plans, though an official start date is up in the air.

Originally floated in May, RCD is a revised version of the Pre-Claim Review Demonstration (PCRD) that launched in August 2016 and was halted in April 2017 after widespread backlash from the home health industry. The demonstrations, according to CMS, are meant to combat improper billing through more rigorous claims review procedures.

While PCRD was largely rigid in structure, the RCD revival gives home health agencies moderately more flexibility. CMS has already announced many details regarding how the new demonstration will work. The agency is now starting to provide answers to remaining questions, including affirmation rate specifics, spot-checking details subsequent options.


The RCD will be a five-year demonstration in Illinois, Ohio, North Carolina, Texas and Florida, according to CMS.

Currently, CMS plans to begin the selection period in Illinois — the same state where the initial Pre-Claim Review Demonstration launched in 2016 — on Dec. 10. However, the agency is still working on receiving full approval under the Paperwork Reduction Act, and will not make any moves until that happens.

Home health agencies operating in active RCD states for the first time will have three immediate options for claims review and approval. Those options include a 100% pre-claim review, a 100% post-payment review and a minimal review option that includes a 25% payment reduction.


Agencies that choose the pre-claim review or post-payment review option and maintain high compliance levels will then be eligible for additional options. Specifically, a high compliance level is deemed as a 90% claims approval rate — or affirmation rate — based on a minimum of 10 requests or claims submitted.

Affirmation rates will be calculated every six months.

The additional options include a 100% pre-claim review, a selective post-payment review and a spot-check review of 5% of claims on a biannual basis.

Illinois providers who participated in the original PCRD and met the 90% threshold under CMS’ desired conditions can jump straight to the bundle of additional options. The home health industry called for clarification on that point earlier this year, after RCD was introduced.

CMS has stated that RCD will not create any new documentation requirements or alter the Medicare home health benefit. Similarly, patient access to home health services will not be delayed or hindered, according to the agency.

The initial implementation of the PCRD in Illinois was riddled with inconsistencies and confusion. Some home health agencies had to hire additional staff just to handle added paperwork and administrative requirements as well.

Estimated savings from the original implementation through March 2017 could have been as high as $1.9 billion, according to a report from the Government Accountability Office.

CMS provided update information on the RCD during an open forum Wednesday afternoon for home health, hospice and durable medical equipment providers.

Written by Robert Holly

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