Review Choice Demonstration: Streamline Pre-Claims Process

Post-Acute Care
Review Choice Demonstration: Streamline Pre-Claims Process

Review Choice Demonstration (RCD) has turned into a major bone of contention between CMS and home health care advocates in the recent time leading up to its implementation. With COVID putting a dent into the plans made by CMS and missteps on the part of its contractors, there has been no shortage of delays. Even with all of its flaws and the backlash RCD implementation is receiving from home health associations in the five participating states, like the winter, it is coming. Let’s find out what RCD is all about.

What is Review Choice Demonstration? 

Review Choice Demonstration has been implemented to help ensure that the right payments go through at the right time for all home health services disbursed. The claim reviews will protect Medicare from disbursing improper payments, further reducing the number of Medicare appeals and improve provider compliance with Medicare program requirements.

It can also help prevent all fraud and misuse of Medicare benefits and help educate Home Health Agencies(HHA) about their compliance requirements. Agencies participating in RCD will get to choose from three types of claim review submissions to Palmetto GBA:

Seeks provisional affirmation of claim coverage before a final claim payment submission. Claims submitted without a Pre-Claim review undergo prepayment review and are subject to a 25% payment reduction.

1) Spot Check Review

Palmetto GBA selects 5% of HHA claims every 6 months for review, sharing Additional Document requests to follow CMS prepayment review procedures.

2) Post-Payment Review

Seeks review of claims after a claim payment submission, also is the initial default if no selection is made by the HHA. Palmetto GBA, the Medicare Administrative Contractor (MAC), sends Additional Documentation Requests (ADRs) to follow CMS' post-payment review procedures.

3) Selective Post-Payment Review

Involves analyzing a random sample of claims

4) Minimal Post-Payment Review

All claims are subject to a 25% reduction in final payment. Claims are excluded from Targeted Probe and Educate reviews but can still be subject to Recovery Audit Contractor Reviews. Once selected, the provider remains active on this choice for the duration of the Demo.

Every six months thereafter, home health agencies demonstrating compliance with Medicare rules through pre-claim or post-claim reviews have additional choices, including relief from most reviews except for a review of a small sample of claims. If an agency maintains a 90% or greater pre-claim review affirmation rate or post-payment review approval rate, it chooses from a different subset of review options, mainly,

Why the Review Choice Demonstration for Home Health Agencies Is Proving to Be Challenging

One might say, it all looks like a neat deal that will help reduce the misuse of Medicare funding, but the rollout of Review Choice Demonstration has been anything but smooth for HHAs. With the pandemic wreaking havoc in the participating states, especially Florida & North Carolina, skyrocketing referral rates, and clinical staff stretched thinner than paper home health agencies are already struggling with huge claims backlogs. Since RCD is another compliance-related process, it comes across as a burden to organizations in these trying times, drawing flak from prominent voices in the homecare industry.

Another major concern for the organizations is that the introduction of the claim review  process will add to the encumbrance of manual, repetitive administrative tasks, which there is no shortage of in the home care industry. The amount of time spent transposing EHR data onto Palmetto GBAs platform to start the claim review process is extremely time-consuming and labor-intensive. Coupled with data transfer between the EHRs and Palmetto GBA, there is ample scope for errors to creep in, both technical and human, and this problem has the perfect solution: Automation.

Simplifying the process for home health agencies participating in the Review Choice Demonstration 

Workflow automation solutions designed to automate the claims review process of Review Choice Demonstration can perform all rule-based documentation for clinical teams. The entire claim review process, right from accessing EHR records to uploading them onto Palmetto, extracting responses from Palmetto, and uploading them into the EHRs after applying relevant business rules and audits, automation can do it all, and more.

How to automate the pre-claim review process

Powered by Artificial Intelligence (AI) & Robotic Process Automation (RPA), workflow automation has been working wonders for its early adopters in the home health industry. It is helping clinical staff save hundreds of hours on mundane administrative work, enabling them to focus on utilizing that time towards better patient and self-care, improving job satisfaction, and thereby decreasing turnovers. While speaking about automation in the same line as job satisfaction might seem counterintuitive to some, there is plenty of research on the link between mundane, repetitive work and low job satisfaction.

Check out the video on exactly how automation will simply your claim reviews for RCD

Once you complete watching the video, you might think “this is what our staff does”, and to that, we say, EXACTLY. All actions that you see being performed in the video, were done without any human intervention. Workflow automation can remove the chance of errors in claims and ensure seamless revenue recognition, allowing care staff to disburse the best patient care and the organization to remain compliant with zero operational inefficiencies.

It is a win, win situation for home healthcare, we dare say.