‘It’s Just Wrong on Every Level’: Home Health Insiders Object to Review Choice Demonstration Details

The rollout of the U.S. Centers for Medicare & Medicaid Services’ (CMS) Review Choice Demonstration (RCD) has been anything but smooth.

The initiative implemented to reduce improper billing and fraud in select states has been plagued by issues like COVID-19-related delays and missteps by CMS and its contractors, among others.

Despite the flaws, the demo is still coming. The new selection-effective date is Sept. 1.

“Some of these providers may have kind of gotten conditioned to thinking, ‘Oh, this is just going to keep getting kicked down the road,’” Matt Wolfe, a partner at law firm Parker Poe, told Home Health Care News. “But we’re essentially a week away from the new selection-effective date, and I have not gotten any impression that this is going to get pushed further.”

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Update: ‘This Is the Biggest Break We’ve Had’: CMS Makes Major Alteration to Review Choice Demonstration”

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RCD states include Illinois, Ohio, Texas, North Carolina and Florida. The latter two states are the ones that will be thrown full-go into the process on Sept. 1.

“It’s not being pushed,” Melinda Gaboury, the CEP of Healthcare Provider Solutions, told HHCN. “It’s on Sept. 1, period.”

The Nashville, Tennessee-based Healthcare Provider Solutions is a consulting company that helps home health and hospice agencies with billing, revenue management, coding and other areas of operations.

On a scale of “ready to not ready,” both Wolfe and Gaboury have seen home health providers in both camps, plus some in the middle. Plenty of providers have prepared themselves adequately, subjecting themselves to pre-claims review even prior to the start date.

That has given them the ability to troubleshoot the process as well as familiarize their staff with the new norm.

“It’s a mix between the two: There are agencies in both Florida and North Carolina that have been participating 100% for quite some time,” Gaboury said. “So those providers are not concerned at all. And then there are ones that have been sending, you know, 25% or 30% [of claims]. But then there are some that haven’t started at all. So it’s all over the board. It’s just all over the place.”

There are three options for RCD-participating providers: pre-claims review, a 100% post-payment review or a minimal review with 25% reduction on all payments.

“That third option is really not a realistic choice. I’m not aware of any providers that are choosing the 25% payment reduction,” Wolfe said. “I would be surprised if any are doing the post-payment review option either. That would be pretty grueling to subject all of your claims to post-pay review, and, frankly, that would create a lot of risk. Because if there are any issues with your documentation, it’s not just that you’re not going to get paid for it going forward, you have to pay it all back for all the services that you may have provided.”

Other than the providers simply not being ready for the Sept. 1 start date, the two other biggest concerns are the rise of COVID-19 cases and a current stipulation that would subject claims made prior to Sept. 1 to RCD, retroactively.

In other words, if the dates of service were in May of this year, but then a client isn’t billed until September, the provider would be subject to the post-Sept. 1 rules of RCD. Right now, those claims would still be subject to a Unique Tracking Number (UTN).

“That’s the big concern right now,” Gaboury said. “And it just isn’t fair. If it’s not fully required until September, why are they going to make them go back and do one in May?”

Advocacy groups and providers have tried to fight this aspect of RCD to CMS, but no changes have been made as of now.

“Again, it’s not going to matter for the agencies that have been participating 100% already. They won’t care,” Gaboury said. “But the ones that were told it was phasing in will. They were told they didn’t have to participate, and now all of a sudden, they’re having to participate 100% retroactively. It’s just wrong on every level.”

Additionally, Gaboury and others are worried that providers are becoming too used to more lenient processes in pre-claims reviews that won’t exist in the future.

In the home health proposed rule, CMS confirmed again that if a non-physician practitioner certifies a patient for home health, that non-physician must be the one to do the face-to-face encounter or must certify that a face-to-face encounter occurred in a facility from which the patient was directly referred to home health.

“But right now under PCR review, they will accept any community physician face-to-face note, and they will accept a face-to-face note from a facility whether the facility is the one that referred the patient to home health or not,” Gaboury said. “And the regulation is clear that they can’t do that, and they’re doing it anyway.”

The concern is that if the providers getting used to this do not adjust their ways, they will be subject to an audit down the road that won’t take kindly to that violation.

RCD and COVID-19

Due to the Delta variant, COVID-19 cases are rising yet again across the country. As of Aug. 22, the seven-day average of COVID-19 cases was nearing 150,000, a mark that hadn’t been touched since late-January, according to New York Times data.

In North Carolina, the seven-day average has eclipsed 5,000 cases, a sharp rise from even July and a number that had not been reached since early February in the state. Florida’s seven-day average is over 23,000 — an unprecedented number in the state.

When the selection effective date was set for August of 2020, providers and advocacy groups fought hard against the looming date, ultimately getting it pushed back.

Now, as another selection effective date nears, cases are rising in a similar fashion. CMS obviously could not have guessed that the Delta variant would be wreaking havoc again on these states once this date came, but nonetheless, it is.

“It’s unfortunate and it’s not anyone’s fault,” Wolfe said. “But we’re seeing higher hospitalization rates, particularly in parts of Florida and North Carolina, than we saw even in the worst stages of 2020 and early 2021. And with the higher hospitalization rates, you have more pressure on post-acute care providers like home health agencies. And they have to focus their limited resources on providing the services to get those patients out of those hospitals.”

There’s also a possibility based on the COVID-19 trends in these areas that things get worse before they get better.

Meanwhile, home health providers will be subject to a new way of doing things with RCD — a process that requires more legwork from each provider, as COVID-19 does.

“The ones who have been able to utilize this voluntary process, I think they’re still feeling good,” Wolfe said. “And then there are some that I think just have — understandably — been focused on so many other things and really haven’t dedicated the resources to get ready. And those are the providers I’m most concerned about.”

The COVID-19 surge is also making staffing an even larger issue than it already was.

But the staffing roles that will help manage RCD — the back-end types — have not been easy to fill either.

“The folks who are going to be leaned on most heavily to help out with this RCD are going to be typically the non-direct care workers, the people in the office on the billing side,” Wolfe said. “And it’s hard to hire those positions right now, just because there’s so much demand for those kinds of skills. And, frankly, those people are pursuing options sometimes in other industries.”