CMS Announces New ‘Phased-In Approach’ to the Review Choice Demonstration

The U.S. Centers for Medicare & Medicaid Services (CMS) announced Friday it will not resume a full-blown resumption of the Review Choice Demonstration (RCD) for home health agencies in participating states later this month.

Instead, CMS is “phasing in” RCD for agencies in North Carolina and Florida. Agencies in Illinois, Ohio and Texas will be granted flexibilities as well, according to CMS, which cited the current public health emergency as the reason for the newly announced RCD relief.

Despite ongoing operational challenges associated with the COVID-19 virus, CMS officials originally said in early July that the home health industry would once again be subject to RCD demands beginning Aug. 3. Broadly, RCD is a regulatory initiative meant to reduce improper billing by providers by requiring them to undergo pre-claim review, pre-payment review or post-payment review, among other options.

“Given the importance of review activities to CMS’s program integrity efforts, CMS will discontinue exercising enforcement discretion for [RCD] … regardless of the status of the public health emergency,” officials wrote in their July update.

Home health providers and advocates immediately pushed back on that announcement, arguing that CMS’s timing was “heartless” and “hypocritical.”

But over the past few weeks, industry stakeholders were able to meet with several key officials from the agency’s Office of the Administrator and Center for Program Integrity, Tim Rogers, president and CEO of the Association for Home & Hospice Care of North Carolina, told Home Health Care News in an email.

Ultimately, those stakeholders — a combination of providers, state associations, the National Association for Home Care & Hospice (NAHC) and the Partnership for Quality Home Healthcare (PQHH) — were able to get their point across, Rogers noted.

“We detailed every scenario we we could regarding hardships and RCD,” Rogers said. “[This is] a great example of when state associations and their members push hard on advocacy, with strong support from our national associations like NAHC and PQHH.”

Specifically, for North Carolina and Florida, agencies may submit pre-claim review requests for billing periods beginning Aug. 31.

Claims that go through pre-claim review and are submitted with a valid UTN will be excluded from further medical review. Claims submitted without going through the pre-claim review process will process as normal and will not be subject to a 25% payment reduction.

Moving forward, claims may be subject to post-payment review in the future through the normal medical review process, according to CMS.

On their end, providers who have already made a choice selection do not need to take any further action if they choose not to participate in RCD at this time.

CMS will reassess the “phased-in approach” in 60 days.

“Providers may choose to send in a handful of claims through the RCD platform to get their feet wet,” said Rogers, who also serves as chair for The Council of State Home Care & Hospice Associations and has a leadership role at the South Carolina Home Care & Hospice Association. “This will enable them to be confident and comfortable when RCD is required.”

Matt Wolfe, a partner at law firm Parker Poe, described CMS’s announcement as “an important” and “helpful” recognition of the need for home health providers to focus on quality clinical care and serving their communities during the COVID-19 spikes sweeping parts of the nation.

“The voluntary option also allows home health agencies to trial the pre-claim review process without putting their cash flow and operations fully at risk,” Wolfe told HHCN in an email. “I am hopeful that CMS will use this approach as a model moving forward for overseeing providers in a thoughtful and measured manner.”

While agencies in Illinois, Ohio and Texas aren’t afforded as many RCD flexibilities, they will likewise see some regulatory relief.

Cycle 2 in Illinois and Cycle 1 in Texas will end on Sept. 30. Affirmation and claim approval rates will be calculated based on review decisions made between Feb. 1 and Sept. 30 for Illinois providers, and between March 2 and Sept. 30 for Texas providers.

Cycle 2 in Ohio will begin on Aug. 31, as CMS previously noted.

Claims submitted under Choice 1 without going through the pre-claim review process will not be subject to a 25% payment reduction until further notice, but will be subject to pre-payment review.

“We consider this to be a victory,” Rogers said. “A very flexible situation for our providers, in fact, and a recognition of the serious nature of … this pandemic and the role home health caregivers are playing in the care continuum in North Carolina and Florida now, which was one of my stresses to CMS.”

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‘An Absolute Travesty’: Home Health Advocates Make Last-Ditch Effort to Delay Review Choice Demonstration

When the U.S. Centers for Medicare & Medicaid Services (CMS) announced that the Review Choice Demonstration (RCD) would resume for participating states in August, home-based care providers and advocates were up in arms over the decision.

But as the resumption date approaches, industry advocates are making a last-ditch effort to get CMS’s attention and persuade regulators to reconsider the move.

“I think it’s one of the most heartless, callous and hypocritical decisions that CMS could make at this time,” Tim Rogers, the president and CEO of the Association for Home & Hospice Care of North Carolina, told Home Health Care News.

RCD states include Illinois, Ohio, Texas, North Carolina and Florida. The latter two are just being introduced to the improper billing initiative.

In part, the resumption of RCD is so brutal due to recent developments in the battle against the coronavirus. Both Florida and North Carolina have rising COVID-19 case trends, according to data from John Hopkins University.

Currently, RCD is supposed to begin again on Aug. 3. Originally, the thought was that as long as a public health emergency persisted, CMS would continue its suspension of RCD.

But the public health emergency has been extended to at least Oct. 23, and CMS — as of now — is planning on moving forward with the demonstration despite that extension.

Rogers worked with the executive director of the Home Care Association of Florida (HCAF), Bobby Lolley, as well as the Partnership for Quality Home Healthcare, among other advocacy groups, to originally get a delay implemented when the COVID-19 crisis began.

“They listened to our concerns months ago, and they implemented the delay,” Rogers said.

“We never were led to believe that it was going away.”

Two weeks ago, Lolley helped lead an effort to get U.S. senators involved. Republican Senator Marco Rubio had helped similarly with the Pre-Claim Review Demonstration (PCRD), RCD’s failed predecessor.

Naturally, HCAF and Florida home health providers looked to enlist his help once again.

And those efforts paid off: Rubio’s staff reached out to CMS on behalf of the providers who voiced concerns to them about the resumption of RCD. In turn, CMS asked that providers send them emails directly about their reservations.

As of Friday, over 1,000 emails had been sent to CMS. More than 4,600 RCD-related emails have been sent total, whether that be to politicians, advocacy groups or government agencies, Lolley told HHCN.

“That is a good-sized number, but it needs to be bigger, and we’re going to be pushing this week to make that number larger,” Lolley said. “So if these emails from providers get the attention we think, I think that’ll lead into us getting some sort of meeting with someone higher up in CMS.”

Advocates involved in the effort hope to double those numbers by week’s end.

Lolley said that he is hoping that CMS’s decision was simply an oversight and that, once things get talked out, the agency will understand why this is the wrong move amid a national health care crisis.

“If we can just talk to them and make sure that they understand how difficult things are for the home health sector here in Florida … I can’t imagine anybody going forward with this,” Lolley said. “I don’t think it will go away. But I do feel fairly confident that they would delay it. How long would they delay it? I’m not sure. But I do believe that if it just can be brought to the attention of the right people, they’ll see clearly that this should not happen.”

Why RCD hurts right now

In Florida, the hospitals have teetered around full capacity for over a month. When it gets to that level, hospitals need to start pushing out their more stable patients — and that’s when home health really comes in handy.

That means that referrals for home health agencies have been through the roof, Lolley said, and that running an agency is more hectic than ever.

Additionally, because of the virus’s resurgence in the state, many administrative and clerical staff are still working from home or working in a COVID-19-related position for the time being.

In North Carolina, many home health agencies owned or managed by hospital systems have begun helping out by sending workers to conduct testing where they’re needed or doing other COVID-19 type work, Rogers said. Those are the ones that would be utilized in RCD work previously.

“These staff members that would be the ones doing the documentation or reviewing the documentation prior to the claim submission are now remote,” Rogers said.

Even without COVID-19 circumstances, RCD is a bit of an undertaking for home health providers.

Now, given the increased referrals and new regulations, providers feel that it is just unfair to bestow another burden on them right now, Linda Murphy, the founder and COO of Concierge Home Care in Florida, recently told HHCN.

“I think CMS’s timeline is aggressive considering the state of emergency,” Murphy said. “We are seeing a spike in quarantined team members due to outside exposures. We are now mandated to test our team members every two weeks. … We are [already] asking so much of our clinical teams to meet the challenges and demands.”

Concierge Home Care is a home health provider with nine locations in northern Florida.

While CMS is resuming RCD, it is simultaneously still allowing — and encouraging — remote patient monitoring, non-physician home health certification and hospital-to-home health hand-offs, in general. That seems backwards to advocates for RCD suspension.

CMS is acknowledging the increasingly large and tough role home health plays while also increasing its burden amid COVID-19, they feel.

That’s why Lolley, Rogers and others feel so strongly about their cause. They’re going to keep hitting up members of Congress, CMS and anyone else who will listen over the next week.

Congress withholds the right to halt CMS from moving forward with RCD re-implementation.

“They classify home health as such an important aspect of the clinical continuum during COVID-19,” Rogers said. “And then they augment them and push them aside during COVID-19 in order for them to do RCD, audits and paper chase, and ultimately diminish their role in clinical care — it’s an absolute travesty.”

Rogers and Lolley are both cautiously optimistic that they’ll be able to get something done and are hoping it will be by this upcoming Friday, July 31.

“Granted, if it were implemented, we would complete our learning curve just like Illinois, Ohio and Texas,” Lolley said. “But they didn’t have a learning curve in the middle of a worldwide pandemic, and their state wasn’t in the center of that virus. The timing, it’s just crazy. It’s crazy to try to do this.”

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