Review Choice Demonstration –Project Update & PGBA Workshop Series in Texas June 18 and 19th

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By Marissa Machado posted 9 days ago

  

As previously reported, Illinois home health agencies have until this Thursday, May 16, 2019 to make their Review Choice Demonstration (RCD) choices. 

Illinois Providers must be enrolled in Palmetto GBA’s eServices in order to make their selection. HHAs that do not make a choice selection by May 16, 2019 will be automatically placed in either Choice 2: Postpayment Review (for those IL providers new to RCD or not having an affirmation rate of 90% or greater) or Choice 4: Selective Postpayment Review (for those Illinois providers with an affirmation rate of 90% or greater (based on a 10 request/claim minimum).

Following the close of the choice selection period, the demonstration will begin in Illinois on June 1, 2019, and all episodes of care starting on or after this date will be subject to the requirements of the choice selected. The choice selection process must be done through the Palmetto GBA eServices portal. Illinois HHAs should visit the Palmetto GBA provider portal here for information and instructions on the eServices enrollment process (if not already enrolled) as well as the RCD choice selection process. Palmetto GBA also sent a letter to all Illinois HHAs detailing the choice selection information and the HHA’s affirmation rate for the previous Pre-Claim Review project. If your agency is located in Illinois and has Palmetto GBA as your Medicare Administrative Contractor (MAC) and you did not receive a letter, you should go to the Palmetto GBA eServices portal or contact the Palmetto GBA provider contact center at 1-855-696-0705 from 8:00 AM to 4:30 PM Eastern Standard Time (EST). 

Please note: If a provider has multiple NPIs but with one PTAN – each NPI is to make a RCD selection as each NPI has its own calculated rates.

There are a total of five states that are part of the RCD – Illinois, Ohio, North Carolina, Florida, and Texas. As stated above, Illinois will begin again on June 1, 2019. CMS has indicated it will provide 60 days notice before the Demonstration begins in any of the other four states.

 HHAs will initially select between three review choices:

  • Choice 1: Pre-Claim Review,
  • Choice 2: Postpayment Review, or
  • Choice 3: Minimal review with a 25% payment reduction. (HHAs that select this choice will remain in this choice for the duration of the demonstration regardless of their claim approval rate).

HHAs who do not actively select one of the initial three review choices will be automatically assigned to participate in Choice 2: Postpayment Review.

HHA will have until two weeks prior to the start of the demonstration in their state to make their choice selection. HHAs can make their selection by utilizing the Palmetto GBA eServices online provider portal (link above). HHAs may select from one of the three review choices available to them. HHAs should be sure to read each choice thoroughly prior to making a selection as some selections will be locked-in for the duration of the demonstration.

HHAs who select either Choice 1 or Choice 2 will be evaluated for 6 months. If the HHA’s full affirmation rate or claim approval for those 6 months is 90 percent or greater (based on a minimum of 10 submitted pre-claim review requests or claims), the HHA may select one of the three subsequent review choices:

  • Choice 1: Pre-Claim Review,
  • Choice 4: Selective Postpayment Review, or
  • Choice 5: Spot Check Review.

HHA’s that do not actively choose one of the subsequent review options will automatically be assigned to participate in Choice 4: Selective Postpayment Review, and will remain there for the duration of the demonstration.

Please note: Palmetto has indicated it is reaching out to all HHAs choosing either Choice 3 or Choice 4 to be certain these providers understand the choice is permanent for the duration of the Demonstration. In such HHAs, if the person submitting records is not the person the HHA wants Palmetto or the RCD reviewer to contact with questions, Palmetto suggested the HHA should put the name of the desired contact person in the Submitter box that appears in the RCD choice selection process.

If the HHA’s rate is less than 90% or they have not submitted at least 10 requests/claims, the HHA must again choose from one of the initial three options.

Illinois HHAs who previously participated in the initial pre-claim review demonstration and met the 90 percent target full provisional affirmation rate (based on a minimum 10 requests submitted) can also select from the three subsequent review choices above, and do not need to start in one of the initial three review choices.

There are several more important items of note relative to the RCD below:

  • A HHA’s affirmation rate is calculated on the initial submissions and any resubmissions. If a provider believes they have an incorrect calculation they are to contact the Palmetto PCC and request a review of the calculation.
  • Palmetto GBA has indicated that HHAs under a Targeted Probe & Educate (TPE) review with Palmetto will be removed from the TPE when the RCD begins in their state and after the provider has completed the TPE round it is in when the RCD begins. Providers will not be under both reviews simultaneously. Additionally, an HHA under a UPIC (Unified
  • Program Integrity Contractor) is not eligible for the RCD. Any such providers may receive a letter from Palmetto indicating this. If the RCD is occurring in their state when the UPIC review is completed, the HHA will need to make an initial RCD choice. This does not mean claims that are part of the RCD will never be reviewed by a UPIC. They may be subject to UPIC review if fraud is suspected. Also, claims may be selected as part of the CERT (Comprehensive Error Rate Testing) sample. Again, claims falling under RCD will be excluded from regular MAC TPE reviews.
  • CMS has published a RCD HH Operational Guide that all providers effected by RCD should review. There are also several other helpful resources for RCD available from Palmetto. They are located at the Palmetto GBA Home Health Review Choice Demonstration webpage.
  • TAHC&H you’re go-to industry leader is offering educational opportunities on RCD. Texas is hosting a Palmetto GBA workshop series for RCD that includes 2 dates in June, 18 & 19. TAHC&H is very excited to offer a “live stream” workshop option on the June 19th. Register today to secure your seat for this important workshop. 

For more information on TEXAS RCD workshops, please visit: https://tahch.org/education/upcomingevents.

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