RCD Update: Pre-Claim Review LUPA Phase-In

CMS and Palmetto GBA have announced a phase-in approach of Low Utilization Payment Adjustments (LUPAs) within the Review Choice Demonstration (RCD) in the wake of PDGM.

Here is the LUPA phase-in timeline that Palmetto GBA provided in a recent update:

• Prior to January 1, 2020, LUPAs were excluded in the Pre-Claim Review (PCR). Episodes of care with four or fewer visits were considered LUPAs and paid on the standardized per visit payment instead of a payment for a 30-day period of care.
• For 30-day period start dates between January 1, 2020 and March 31, 2020, LUPAs with four or fewer visits do not require a PCR request submission. However, each claim will be reimbursed based on the PDGM LUPA threshold. LUPAs with five or more visits will require a PCR request. If no PCR request is submitted, an Additional Documentation Request (ADR) will be issued to the agency and they will receive a 25% reduction in payment on the full claim amount.
• For 30-day period start dates on or after April 1, 2020, all LUPAs must have a PCR request or an ADR will be issued, and the agency will receive a 25% payment cut on that claim.

A 25% payment reduction for not submitting a PCR request for LUPAs is a significant loss in reimbursement. It is imperative review your PCR process for possible updates and notify staff to prepare and submit a PCR request for all 30-day period claims.

Read the full article on the Palmetto GBA website for additional guidance on the LUPA Phase-In.

Watch our webinar Strengthen Clinical Compliance for Review Choice Demonstration to prepare your agency for RCD and help avoid significant cuts to your revenue.