RCD: More on the CMS FAQs Update

Last week, CMS updated its Frequently Asked Questions (FAQ) on the pending Review Choice Demonstration (RCD) project. Some of these merit additional scrutiny and comment since the selection window (via Palmetto GBA’s eServices portal) has started for Illinois home care agencies. Taken from the “Review Choice Demonstration (RCD) for Home Health Services Frequently Asked Questions (FAQs)”, updated 4/18/19. Check out Part 1 here.

This is Part 2 of QIRT experts’ comments intended to help clarify the FAQs.

Additional thoughts on some items of interest.

Question 18. Are beneficiaries covered under a Medicare Advantage Plan included in the RCD?

Answer: No, the RCD demonstration only applies to Medicare beneficiaries covered under Fee-for-Service (FFS) Medicare.

QIRT Comment: At this time, Medicare Advantage (MA) claims are not affected by RCD.  It remains to be seen when various MA providers may choose to follow Medicare’s lead, but for now, they remain under current MA payment requirements.


Question 24. Will claims reviewed under the demonstration still be subject to additional review?

Answer: Absent evidence of potential fraud or gaming, the claims that have a provisional affirmation pre-claim review decision or where approved under medical review will not be subject to additional review. However, CMS contractors, including Unified Program Integrity Contractors and Medicare Administrative Contractors, may conduct targeted prepayment and post-payment reviews to ensure that claims are accompanied by documentation not required or available during the pre-claim review process. In addition, the CMS Comprehensive Error Rate Testing (CERT) program reviews a stratified, random sample of claims annually to identify and measure improper payments. It is possible for a home health claim that is subject to pre-claim or post-payment review to fall within the sample. In this situation, the subject claim would not be protected from the CERT audit.

QIRT Comment: This is the good news of RCD – the stoppage of Targeted Probe & Educate (TPE) Probes. Palmetto GBA has indicated that TPE Probes in progress will also stop. That UPIC, CERT, and RAC activity can continue still puts agency claims at some risk for medical review. How an affirmed status from RCD may affect these contractors is yet to be seen; although it should be a powerful asset to obtaining a favorable outcome from any UPIC, RAC, or CERT activity.  Conversely, any billed non-affirmed claims may trigger medical reviews and make payment of any reviewed claims very difficult, and well as complicating any resulting appeals of the denials.

Question 27. Where can I send additional questions?

Answer: Additional questions on the pre-claim review model may be sent to CMS at HomeHealthRCD@cms.hhs.gov.

QIRT Comment: A good address to know and to send questions so they may be addressed on CMS’s website and in the CMS and Palmetto GBA webinars.

Question 30. Is eServices the only way to make my RCD selection?

Answer: Yes, providers need to make their selection in the eServices portal.

QIRT Comment: All providers must be on Palmetto GBA eServices. If a provider is on eServices, it makes sense to use their portal as the fastest and easiest method of submission of records for Pre-Claim review, Choice 1.

Question 32. Who can make a selection in eServices?

Answer: The account administrator selected in the eServices portal is the only one that can make a selection for RCD.

QIRT Comment: This is only for the selection of choice. Palmetto GBA has indicated that other agency users can submit records for RCD via their portal.


Question 33. Can I change my selection after one has been made?

Answer: Yes, providers can make and change their review choice selections until the night the selection period ends.

QIRT Comment: To ensure a selection is made timely, one can be selected when the period opens. This will prevent being assigned the default Choice 3 or Choice 4 – both of which lock the agency into that choice for the duration of RCD.

Question 37. When and how will I receive the results of my 6-month review period?

Answer: Results letters will be sent to providers within the 7th month (30 calendar days or 20 business days) from the end of the review cycle. If a provider selects eDelivery in their preferences in eServices, all PCR responses will be sent via eDelivery regardless of what method the PCR request was submitted to Palmetto GBA. Providers that do not select eDelivery will receive the PCR response via mail.

QIRT Comment: This clarifies how subsequent choices will be made. Agencies should then be on the lookout for these results to determine which choices are available and which should be made after the initial 6-month period has been completed.


Question 38. If I select Choice 1: PCR the first 6-month review cycle, then change to Choice 5: spot check for the second 6-month review cycle, will the claims with affirmed UTNs that I will submit during the second 6 months be exempt from spot check review?

Answer: Claims with affirmed UTNs will not be selected for the spot check review.

QIRT Comment: Provisionally affirmed claims should not be subjected to further MAC review.

Question 45. How should we submit PCR documentation in the eService portal?

Answer: For efficiency of review, providers are encouraged to separately attach the documentation by task if the documentation is captured separately as opposed to scanning and attaching one attachment with all the documentation included. If the documentation for several tasks is captured in one document, providers are able to attach the document under one task and then refer to it under each subsequent task. We suggest providers reference the page number(s) in the text box under the subsequent task(s).

QIRT Comment: Palmetto GBA has a submission checklist for both initial and subsequent episodes and a submission form to organize the content. Due to the variability of home health clinical documents, these address the type of document and not specific items. During submission, ensure that the items selected from the record to address each of the tasks for the reviewer are attached to the correct part of the submission.


Question 46. How should providers submit a resubmission through the eService portal?

Answer: Providers that submit a PCR request through the eService portal and receive a non-affirmed or partially-affirmed decision can send a resubmission with additional or updated information in eServices. Once in the eService portal, enter the Unique Tracking Number (UTN) and the portal will pre-populate much of the information that was already submitted. Providers will not need to resubmit attachments that were previously submitted with the original PCR request.

Once the resubmission is in process, providers will receive a message with a new UTN. A separate resubmission is needed for each episode if multiple episodes were submitted and they were not all fully affirmed (i.e., one or more episodes received a non-affirmed or partially-affirmed decision. Note: There must be at least one change to successfully resubmit the request.

QIRT Comment: Ensure that the UTN is included to ensure that the resubmission is matched up to the prior submission. A new UTN will be issued, and this will be important when submitting the final bill for the claim to prevent denial of the claim.  Items must be amended to address the prior non-affirmation reason in order to resubmit.  An agency cannot just resubmit the same documents and hope that a different reviewer looks at the record.


Question 50. If I submit a PCR request and get an incomplete submission response and resubmit with corrections, is it considered an initial or a resubmission?

Answer: This would be considered an initial submission because the original submission was incomplete.

Important: You can avoid incomplete submissions by submitting a PCR request through the Palmetto GBA eService portal at no charge. The eService portal will not allow a provider to submit for PCR with incomplete information and thus avoiding this denial.

QIRT Comment: This is important since the agency affirmation rate (goal of 90% or higher) is based on the total number of submissions.


Question 51. Which physician information do we enter as the certifying in the PCR request if one physician signed the face-to-face (F2F) and another the POC?

Answer: The name and NPI of the physician signing the Certification should be entered on the PCR request. This may or may not be the physician who conducted the F2F encounter.

Reference: MLN Matters SE1219, Page 2

QIRT Comment: In cases with different physicians completing the Plan of Care/certification and conducting the face-to-face encounter, ensure the correct physician information is entered on the pre-claim submission.

Question 56. What will happen if I mis-key the UTN or accidentally leave it off the final claim?

Answer: The claim will Return-to-Provider (RTP) for correction if the UTN is missing or mis-keyed.

Note: If there is no pre-claim review decision on file for a claim submitted by a provider who has chosen Choice 1: Pre-Claim review, the claim will be stopped for prepayment review.

QIRT Comment: Accuracy is important! Prevent any further issues from holding up billing.

Some Choice 1: Pre Claim Review (PCR) Questions:

Question 59. Should documentation supporting the face-to-face encounter be submitted with the pre-claim review request? If so, is it required for each additional episode?

Answer: Yes, documentation supporting the face-to-face encounter must be submitted with the pre-claim review request. You may submit the pre-claim review request at any time prior to the final claim submission to allow time to collect this documentation. Medicare does not require a new face-to-face encounter for additional episodes where the patient has not been discharged from home health care. However, documentation supporting the face-to-face encounter from the start of care should be submitted with the pre-claim review request for subsequent episodes of care.

QIRT Comment: Much like an Additional Development Request (ADR) the certification/initial episode eligibility must be established before any and all subsequent episodes are payable. A “bad” face-to-face encounter will cause all following service to be denied, and thus getting that correct is one of the TOP items in RCD.


Question 61. When submitting the pre-claim review request, does the plan of care need to be signed by the physician?

Answer: Yes, the plan of care needs to include the physician’s signature and date when it is submitted with the pre-claim review request.

QIRT Comment: This may affect the process and timeliness of getting the plan of care signed and dated by the physician. It also means that a pre-claim request cannot be submitted until the plan of care is signed and dated. Check this very carefully and for every pre-claim submission.


Question 62. When should the home health pre-claim review request be submitted?

Answer: The pre-claim review request may be submitted at any time before the final claim is submitted. The pre-claim review process, including submission of the request and receiving the Unique Tracking Number (UTN), must occur before the final claim is submitted for payment. This includes resubmissions after receiving a non-affirmed decision. The pre-claim review request should be submitted when the HHA has obtained all required documentation from the medical record to support medical necessity and demonstrate eligibility requirements are met. Pre-claim review must be requested for each episode of care; however, more than one episode can be submitted on one request for a beneficiary.

QIRT Comment: Must be before final billing or else a UTN will not be assigned.


Question 71. What is a resubmitted request?

Answer: If the initial pre-claim review request was non-affirmed due to an error(s), then a Home Health Agency may resubmit the request with additional documentation as many times as necessary. Medicare will work closely with the Home Health Agency during the pre-claim review process to explain what documentation is needed and why a prior submission was insufficient. A resubmitted request may be for non-affirmed services or for additional episodes that were non-affirmed.

QIRT Comment: If an agency cannot get a provisional affirmation with the original and one resubmission, the claim should be carefully evaluated for disposition. This is either further resubmission or billing without affirmation (which will automatically be denied).


Question 77. Will beneficiaries have to pay for services if a Home Health Agency provides care but ultimately does not obtain a provisional affirmed decision?

Answer: The Limitation on Liability protections of §1879 of the Social Security Act (the Act) will apply to this demonstration. The Limitation on Liability provisions require a provider to notify a beneficiary in advance of furnishing an item or service when such item or service is considered not medically reasonable and necessary, or when a beneficiary is not considered homebound, or when the beneficiary does not need physical therapy, speech-language pathology, skilled nursing care on an intermittent basis, or have a continuing need for occupational therapy, in order to shift financial liability for non-covered care to the beneficiary. In accordance with CMS policies, if an ABN was not issued when required at the start of care and the pre-claim review is non-affirmative, the beneficiary is not financially liable for the care that the HHA provided while awaiting the pre-claim review decision. If the HHA believes that the pre-claim review will be non-affirmative for any of the reasons listed, the provider may issue an ABN in accordance with CMS policy which would allow the beneficiary to choose to receive the service and accept financial liability. The ABN would be effective for denied services furnished after receipt of the ABN. If the HHA expects Medicare to cover the services, an ABN should not be issued. Blanket or routine issuance of ABNs is prohibited under Medicare policy.

Other requirements to qualify for the Medicare home health benefit, such as the face-to-face encounter, are considered technical in nature and are not part of the Limitation on Liability provisions and do not trigger an 1879 of the Act determination. If this documentation is missing then it would be a technical denial, and the provider would be held liable (i.e., not be able to charge the beneficiary) based on 1866(a)(1) of the Act.

When a pre-claim review is non-affirmed, the decision letter will include a detailed written explanation outlining which specific policy requirements were not met. If the non-affirmation is due to one of the reasons listed above that trigger application of the limitation on liability provision, the HHA may issue an ABN and the beneficiary will be held financially liable for denied services received following issuance of a valid ABN. If the non-affirmation was due to documentation errors, the HHA can correct the deficiencies and resubmit the request with all relevant documentation. In this situation, it would not be appropriate to issue an ABN. Also, if the pre-claim review decision is non-affirmed for a reason for which the HHA would otherwise be financially liable (that is, the reason for denial is not one that triggers the limitation on liability provision), the HHA should not issue an ABN following anon- affirmative pre-claim review decision in an attempt to shift liability.

If a provider submits a claim for payment without a pre-claim review request being submitted, the home health claim will undergo pre-payment review. If the claim is determined to be payable, it will be paid but beginning three months after the start of the pre-claim review program in a particular state, there will be a 25 percent reduction to the full claim amount. The 25 percent payment reduction is non-transferrable to the beneficiary.

QIRT Comment: Carefully look at this answer to decide what happens for a non-affirmed claim and continuing agency care for that patient.  ABNs cannot be used to assign liability to the patient.


Question 78. If I receive a partial-affirmed decision for some of the services on my pre-claim review request, do I need to resubmit a new request with just the affirmed services?

Answer: No, you do not need to resubmit a new request with just the affirmed services. These services will be paid once the claim is submitted as long as all other Medicare requirements are met. CMS will monitor the pre-claim review requests to look for those requests where only the affirmed services of a previous request are resubmitted.

QIRT Comment: Partially affirmed claims do not need resubmission of the affirmed portion.


Question 80. What happens if an applicable claim in the demonstration area does not go through pre-claim review?

Answer: If an HHA has selected Choice 1: Pre-Claim Review and submits a claim without a pre-claim review request being submitted, the MAC will stop the claim for pre-payment review. If the claim is payable, it will be paid with a 25 percent reduction of the full claim amount. The 25 percent payment reduction, which applies for failure to receive a pre-claim review decision, is non-transferrable to the beneficiary. Beneficiaries are not liable for more than they would otherwise be if the demonstration were not in place. This payment reduction is not subject to appeal. After a claim is submitted and processed, appeal rights on the claim determination are available as they normally are.

QIRT Comment: Don’t do this.  If Pre-Claim Review Choice 1 is selected, then that means 100% of claims are to be submitted. Get a UTN for every claim (provisionally affirmed is best) prior to final billing to prevent this situation from occurring.


Questions on Additional Choices:

Question 88. What documents are required for the review choices other than pre-claim review?

Answer: The HHA should submit all documentation and information that are currently required for medical review of home health claims. The documentation should support the eligibility and need for the level of services indicated on the claim.

QIRT Comment: ADRs (the method of review for non-Pre-claim review choices) involve much more documents.  Note that while Palmetto GBA applies a 20% allowable error rate for ADRs, the allowable rate under RCD will be 10%.  This is a very challenging bar to reach for many agencies and should be part of the calculation of which RCD Choice is selected.


Question 89. When should the information for those options be submitted?

Answer: The HHA should conduct all standard intake procedures, provide the necessary services, and submit the claim. Once the claim is received, the MAC will send the HHA an ADR. The HHA should submit the documentation following receipt of the ADR.

QIRT Comment: Follow the ADR process. Get the right chart to the right place at the right time with the right content.

General Medicare Home Health Policy and Coverage Questions:

Question 96. If we auto cancel our Request for Anticipated Payment (RAP) could that put us on Zero RAP pay?

Answer: Yes, CMS tracks data for both auto cancels and manual cancels and the Zero RAP pay process will still apply during the RCD demonstration.

QIRT Comment: Behavioral changes including RAP billing can result in other review activity being conducted.  RCD will slow up cash flow enough: losing RAP payment would make things worse.

Palmetto Updates

Palmetto GBA has just updated and posted on its website several useful items. These include:

Palmetto also has multiple conferences and educational activities related to RCD, found at https://www.palmettogba.com/event/pgbaevent.nsf/Home.xsp

Again, a reminder that the choice selection period for home health agencies located in Illinois (who have Palmetto GBA as their MAC) has begun on April 17, 2019, and will end on May 16, 2019.  These agencies should visit the Palmetto GBA provider portal here for information and instructions on the selection process.  As of April 17, 2019, home health agencies are able to view their available choices and make their selection through the portal.  Palmetto GBA will also send letters to all Illinois home health agencies detailing this information.  However, home health agencies do not need to wait to receive their letter.  Home health agencies that do not make a choice selection by May 16, 2019, will be automatically placed in Choice 2: Postpayment Review. 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.

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