The Center for Medicare and Medicaid services (CMS) has proposed updates to the prior 2016 Pre-Claim Review Demonstration (PCRD). This initial demonstration was only rolled out in Illinois but subsequently put on pause in 2017 prior to expanding to additional states. At the end of May 2018, CMS released a notice to providers describing their intention to implement an updated version of the previously paused PCRD. The revision is titled, “Review Choice Demonstration for Home Health Services (RCD).”
Important factors to note include:
- Changes to selected states
- Providers now can select a demonstration method
- Providers can now reach affirmation goal and choose to opt out of the demonstration.
State Selections
In the original demonstration, the difficulties of implementation across multiple Medicare intermediaries has caused CMS to rethink their approach. As a result, CMS has proposed implementing the demonstration in Illinois, Ohio, North Carolina, Florida, and Texas with the option to expand to other states in the Palmetto/JM jurisdiction.
Ability to Select Demonstration Method
Under the new demonstration, providers can select their demonstration type. Download the infographic below for a quick view of how this will work. In short, providers can participate in one of three options:
- 100% pre-claim review
- 100% post-claim review
- Neither, but this option includes a 25% reduction in payments with a potential to be reviewed by Recovery Audit Contractors.
For providers selecting either of the first two options, once a 90% or above target affirmation rate is achieved, providers can remain in the demonstration or opt out and be subject to only periodic claim reviews.
What Does This Mean for Providers?
The new proposal leaves us with many questions that must be answered. However, providers in the RCD states should not wait to act. Begin to understand what documentation is required to provide and begin developing ways to better capture these documents. In many cases, this will require updated workflows to improve capturing, storing, and communicating these documents. Along with the process changes, tools must be developed to ensure the overall process is working and to avoid unnecessary bottlenecks. As appropriate systems are built, providers can feel confident in their ability to take on this new regulation.
