Review Choice Demonstration or RCD was implemented to the timeframe of June 1, 2019 through May 31, 2024. However, due to the success of reduced costs for CMS, it is expected to be expanded further in 2022. In addition, if all goes well, the demonstration may go past 2024. It was initially for Illinois, with the other 4 States added afterward following the standard protocol of 90 days notice before initiation. Many knowledgeable consultants in the market have expressed an expectation that RCD will be implemented across the entire country sooner rather than later due to the results so far. For now, it is important to understand what RCD is so your agency can be prepared for these changes when they occur in your State.
In this article, we will discuss what Review Choice Demonstration is, why it’s important, the phases agencies go through during RCD, and how an EMR can help agencies.
What is the Review Choice Demonstration? (RCD)
CMS states: “Review Choice Demonstration was created to help develop and improve procedures to identify and prevent fraudulent behavior in the home health sector. RCD protects medicare beneficiaries and patients. In addition, it also minimizes the unnecessary provider burden.”
Why is RCD important?
The program was created by CMS and other government agencies to reduce fraudulent and abusive incidents within the medicare home health benefit program and concurrently reduce costs.
The overall goal of RCD is to make sure the right payments are made on time. RCD protects medicare funding, reduces medicare appeals, and improves home health provider compliance with medicare program requirements.
Phases Agencies Must Go Through
Agencies have three options to choose from regarding the review of their submitted documentation within each of the two phases:
Phase 1 of RCD
Pre- Claim Review (PCR)
The PCR is one of three options that home health agencies must choose prior to the start of phase 1 of RCD. Most agencies select this option as it’s the least impactful to revenue and for other reasons discussed on the webinar.
Specific documents that must be attached in this option are:
- RCD form: 15 pages long that contains information that you must submit for every home health period of care.
- Face to Face documentation
- Plan of Care (POC)
- Physician certification
- Patient qualification for home health services
After you submit the PCR, Palmetto GBA has 10 days to respond with your unique UTN number and if the PCR was approved.
There are three decision options:
- Affirmed: all services have been accepted
- Partially affirmed: some services have been accepted
- Non-affirmed: none of the services have been accepted
- Services can begin prior to a PCR decision
- PCR may include more than one billing period
- If no PCR, then no reimbursement or payment reductions
- UTN, rendering providers, NPI, CCN, HHA name and address are all required on the final claim
Post Payment Review (default)
The second option in phase 1 is the Post Payment Review. If your agency doesn’t choose one of the options then your agency will automatically be placed in the Post Payment Review option.
Criteria for Option 2 is:
- RAPs and final claims
- ADRs will be sent out to the agency
- Must gather all documentation
Minimal Review with Payment Reduction
The third and final option of phase 1 is the Minimal Review with Payment Reduction.
Criteria for Option 3 is:
- 25% payment reduction option
- Applied to all payable claims
- Claims are excluded from probe and education reviews but not from RAC audits
- If your agency chooses this option your organization will stay in this option for the remainder of the demonstration (will not move into phase 2)
Reminder: After six months of compliance with an affirmation rate of 90% or better, the agency will be allowed to move into phase two and select one of the three options. If an agency doesn’t meet this requirement, they must repeat phase one.
Phase 2 of RCD
During Phase 2, PCR is the exact same as Phase 1 (see Phase 1 section)
Selective Review (default)
Just like in Phase 1, if your agency doesn’t choose an option then your agency will be automatically placed into the Selective Review option.
Criteria for Option 2:
- RAPs and final claims just like in phase 1
- SVRs every 6 months
- Will be sent an ADR for random sample of final claims
Spot Check Option
The Spot Check option is the third and final option in Phase 2.
Criteria for Option 3:
- Medicare intermediary will choose 5% of final claims every 6 months to review
- RAPs and Final claims submitted like usual
Reminder: Whichever option you choose for Phase 2 will be the option used for your organization for the remainder of the demonstration.
How EMR’s can help with RCD
For the five states that must currently submit documentation for RCD it can be challenging to locate all the required elements for an RCD submission, as well as, build the associated file in the required format. In addition, for many EMR’s, this is unfortunately an entirely manual process. Which can be further burdened with PDGM options already in play, like submitting 2 RAP’s concurrently for a clinical episode. Having an EMR to help your agency with these additional RCD administrative burdens can minimize additional required staffing and ensure your agency achieves an affirmation rate of 90% or better.
How KanTime’s EMR can help with RCD
KanTime’s configurable role based dashboards alert agencies to which payment periods require generation of the RCD file. Since KanTime is configurable by Payor, and all three Phase related options can be individually configured, KanTime knows which claims require generation of these files and will block submission of the RAP until they are generated. In addition, Users can see which items need to be satisfied for the claim to be submitted. (see below)
KanTime automatically collects and presents the required elements of the RCD submission file for user selection and affords the opportunity to add additional documentation at User’s discretion. It then builds the file in the required CMS format while concurrently allowing the PDGM option of submitting both RAPs from a clinical episode concurrently.
Once the claims are submitted, the dashboard will organize the patients so the User can see which patients are waiting to be reviewed (see below).
Once the UTN is populated in the field below, KanTime will automatically include it in the appropriate field of the UB04 when the end of payment period claim is generated. (see below)
Even though the program is currently only planned for implementation over five years, based on its success to date, it may go longer and may soon apply to all States. Therfore, it is important for agencies to understand what RCD is and how to successfully submit the initial formatted file with the RAP(to gain the necessary UTN).This then must be included in the end of payment period claims to ensure reimbursement. There is little doubt that additional states will be added as this program progresses. It may indeed be permanent at some point for the entire country. Clearly, your agency must be prepared.
KanTime and Ability teamed up to discuss RCD and how to best apply the available options in the program phases for your organization. They also discussed some of the functionalities KanTime offers to maximize your efficiency when applying these new processes..
The above reflects just some of the compliance and efficiency drivers that KanTime provides to its customers. If you are a more visual learner or want more information watch Ready or Not RCD is Coming!