Review Choice Demonstration for Home Health Services

Update 03/26/2021:

Due to the continuing public health emergency, CMS will continue the phased-in participation of the Review Choice Demonstration for Home Health Agencies in Florida and North Carolina for an additional 90 days. Providers interested in participating should make their Cycle 2 Choice selections between April 1, 2021 and April 15, 2021.  Cycle 2 will begin on May 1, 2021 for those providers. 

  • Providers may choose from a subsequent choice selection based upon their Cycle 1 results.
  • Providers that do not make a choice selection may continue submitting pre-claim review requests.
  • 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. These claims may be subject to postpayment review in the future through the normal medical review process.
  • Providers do not need to take any further action if they choose not to participate.

Update 12/22/2020:

Due to the continuing public health emergency, CMS will be extending the phased-in participation of the Review Choice Demonstration for Home Health Agencies in Florida and North Carolina until 3/31/21.

  • Providers may continue submitting pre-claim review requests.
  • 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. These claims may be subject to postpayment review in the future through the normal medical review process.

Providers do not need to take any further action if they choose not to participate.

Update 10/29/2020:

Due to the continuing public health emergency, CMS will be extending the phased-in participation in the Review Choice Demonstration for Home Health Agencies in Florida and North Carolina until 1/1/21.

  • Providers may continue submitting pre-claim review requests.
  • 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. These claims may be subject to postpayment review in the future through the normal medical review process.
  • Providers do not need to take any further action if they choose not to participate.

Update 08/21/2020:

CMS is phasing in participation in the Review Choice Demonstration for Home Health Agencies (HHAs) in North Carolina and Florida, for a limited period of time, to help ease the transition during the current public health emergency.  Specifically, for HHAs in North Carolina and Florida:

  • Providers may submit pre-claim review requests for billing periods beginning 8/31/20.
    • 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.
    • Claims may be subject to postpayment review in the future through the normal medical review process
  • Providers who have already made a choice selection do not need to take any further action if they choose not to participate.
  • CMS will reassess the phased-in approach in 60 days.

For Illinois, Ohio, and Texas:

  • Cycle 2 in Illinois and Cycle 1 in Texas will end on September 30, 2020.
    • Affirmation and claim approval rates will be calculated based on review decisions made between February 1, 2020 and September 30, 2020 for Illinois providers and between March 2, 2020 and September 30, 2020 for Texas providers.
  • Cycle 2 in Ohio will begin on August 31, 2020, as 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 prepayment review.

Resumption of Demonstration Activities Update 07/07/2020:

Given the importance of review activities to CMS’ program integrity efforts, CMS will discontinue exercising enforcement discretion for the Review Choice Demonstration for Home Health Services, beginning on August 3, 2020, regardless of the status of the public health emergency.  The initial choice selection period will begin in North Carolina and Florida on August 3, 2020 and end on August 17, 2020.  The choice selection period for Ohio’s second review cycle will also begin August 3, 2020 and end on August 17, 2020. 

Following these choice selection periods, home health claims in all demonstration states (Illinois, Ohio, Texas, North Carolina, and Florida) with billing periods beginning on or after August 31, 2020 will be subject to review under the requirements of the choice selected.  This includes pre-claim review, prepayment review, and postpayment review.

Following the resumption of the demonstration, the MAC will conduct postpayment review on claims subject to the demonstration that were submitted and paid during the pause.  CMS will post more information on the postpayment review process in the near future.

Please see Provider Burden Relief Frequently Asked Questions (PDF) for more information.

Update 03/31/2020:

On March 30, 2020, CMS announced a pause of certain claims processing requirements for the Review Choice Demonstration (RCD) for Home Health Services in Illinois, Ohio, and Texas until the Public Health Emergency for the COIVD-19 pandemic has ended.  In addition, the demonstration will not begin in North Carolina and Florida on May 4, 2020 as previously scheduled.  Please see here (PDF) for more information.

Update 03/13/2020:

The choice selection period for Home Health Agencies (HHAs) located in North Carolina and Florida will begin on March 20, 2020 and end on April 19, 2020. HHAs should visit the Palmetto GBA provider portal here for information and instructions on the selection process. Through the portal, HHAs will be able to view their available choices and make their selection. Palmetto GBA will also send letters to all Florida and North Carolina HHAs detailing this information.  HHAs that do not make a choice selection by April 19, 2020 will be automatically placed in Choice 2: Postpayment Review. Following the close of the choice selection period, the demonstration will begin in North Carolina and Florida on May 4, 2020, and all billing periods starting on or after this date will be subject to the requirements of the choice selected.

In addition, CMS will continue the phase-in to include Low Utilization Payment Adjustments (LUPAs) within the demonstration. All LUPAs will be included in RCD beginning April 1, 2020.

CMS will continue to post updated information on this website. Please send any questions to: homehealthRCD@cms.hhs.gov.

Update 01/16/2020:

The choice selection period for Home Health Agencies (HHAs) located in Texas began on January 15, 2020 and will end on February 13, 2020. HHAs should visit the Palmetto GBA provider portal here for information and instructions on the selection process. Through the portal, HHAs will be able to view their available choices and make their selection. HHAs that do not make a choice selection by February 13, 2020 will be automatically placed in Choice 2: Postpayment Review. Following the close of the choice selection period, the demonstration will begin in Texas on March 2, 2020, and all billing periods starting on or after this date will be subject to the requirements of the choice selected.

Following the start of the demonstration in Texas, the demonstration is expected to begin in North Carolina and Florida on May 4, 2020.  In addition, CMS will phase-in the inclusion of Low Utilization Payment Adjustments (LUPAs) within the demonstration. CMS will continue to monitor the transition to the Patient-Driven Groupings Model (PDGM) and will post updated information on this website. Please send any questions to: homehealthRCD@cms.hhs.gov.

Update 01/06/2020:

CMS has updated the Frequently Asked Questions and the Operational Guide to include additional information on how the PDGM will affect the demonstration.  Please refer to the documents in the “Downloads” section below.

Update 10/21/2019: CMS reschedules next phase of Home Health Review Choice Demonstration

To allow HHAs to transition to the PDGM which becomes effective on January 1, 2020, CMS is rescheduling the implementation of the Home Health Review Choice Demonstration (RCD) for the remaining states of Texas, North Carolina, and Florida. The demonstration is expected to begin in Texas on March 2, 2020. The choice selection period will begin on January 15, 2020 and end on February 13, 2020 for HHAs located in Texas, who submit claims to Palmetto GBA, the Jurisdiction M Medicare Administrative Contractor.  

HHAs should visit the Palmetto GBA provider portal for information and instructions on the RCD selection process. Through the portal, HHAs will be able to view the three initial review choices and make their selection. Palmetto GBA will also send letters to all Texas HHAs detailing this information. HHAs that do not make a choice selection by February 13, 2020 will be automatically placed in Choice 2: Post payment Review. 

Following the close of the choice selection period, the demonstration is expected to begin in Texas on March 2, 2020, and all billing periods starting on or after this date will be subject to the requirements of the choice selected.

Following the start of the demonstration in Texas, the demonstration is expected to begin in North Carolina and Florida on May 4, 2020. CMS will monitor the transition to the PDGM and assess the need for any change to this date.

With the transition to the PDGM, CMS will phase in the inclusion of LUPAs within the Review Choice Demonstration.

CMS will continue to post updated information on this website.

Please send any questions to: homehealthRCD@cms.hhs.gov.

Update 7/29/2019:

The choice selection period for HHAs located in Ohio will begin on August 16, 2019 and end on September 15, 2019. HHAs should visit the Palmetto GBA provider portal here for information and instructions on the selection process. Through the portal, HHAs will be able to view their available choices and make their selection. Palmetto GBA will also send letters to all Ohio HHAs detailing this information. HHAs that do not make a choice selection by September 15, 2019 will be automatically placed in Choice 2: Postpayment Review. Following the close of the choice selection period, the demonstration will begin in Ohio on September 30, 2019, and all episodes of care starting on or after this date will be subject to the requirements of the choice selected.

CMS will continue to post updated information on this website. CMS anticipates 60-90 days between beginning the demonstration in the remaining states of Texas, North Carolina, and Florida. CMS and Palmetto GBA will provide at least 60 days’ notice in advance of the demonstration starting in each additional state. Please send any questions to: homehealthRCD@cms.hhs.gov.

Update 4/3/2019:

CMS received Paperwork Reduction Act (PRA) approval for the Review Choice Demonstration for Home Health Services (the demonstration).  The Office of Management and Budget (OMB) has reviewed the demonstration documents and CMS’ responses to public comments and approved the collection of information. The updated online status is available here.

In response to public comments, the demonstration incorporates more flexibility and choice for providers, as well as risk-based changes to reduce burden on providers demonstrating compliance with Medicare home health policies. HHAs will select from three initial choices:

  • Pre-claim review,
  • Postpayment review, or
  • Minimal postpayment review with a 25% payment reduction. 

After a 6-month period, HHAs demonstrating compliance with Medicare rules through pre-claim review or postpayment review will have additional choices, including relief from most reviews except for a review of a small sample of claims. Illinois HHAs that previously participated in the initial Pre-Claim Review Demonstration for Home Health Services and met the 90 percent target full provisional affirmation rate (based on a minimum 10 requests submitted from August 2016 through March 2017) can begin the demonstration by selecting from the additional choices. Full demonstration details will be available in the Operational Guide published in the ‘Downloads’ section below.

The choice selection period for HHAs located in Illinois will begin on April 17, 2019 and end on May 16, 2019.  HHAs should visit the Palmetto GBA provider portal here for information and instructions on the selection process.  Beginning April 17, 2019, HHAs will be able to view their available choices and make their selection through the portal.  Palmetto GBA will also send letters to all Illinois HHAs detailing this information; however, HHAs do not need to wait to receive their letter and may go to the provider portal starting on April 17, 2019.  HHAs 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. 

With this demonstration’s approval, CMS is better positioned to identify and prevent fraud, protect beneficiaries from harm, and safeguard taxpayer dollars to empower patients while minimizing unnecessary provider burden. The demonstration helps ensure that the right payments are made at the right time for home health service through either pre-claim, prepayment, or postpayment review, protects Medicare funding from improper payments, reduces the number of Medicare appeals, and improves provider compliance with Medicare program requirements. The demonstration should not delay care to Medicare beneficiaries and does not alter the Medicare home health benefit. The demonstration will not create new clinical documentation requirements. HHAs will submit the same information they are currently required to maintain for payment.  

CMS will continue to post updated information on this website. In addition, CMS and Palmetto GBA will provide at least 60 days’ notice prior to the demonstration start date in each of the additional four states. CMS will provide notice on this website before phasing in the other demonstration states: Ohio, Texas, North Carolina, and Florida. Please send any questions to: homehealthRCD@cms.hhs.gov.

Background

On April 1, 2017, CMS paused the Pre-Claim Review Demonstration for Home Health Services to consider a number of changes in response to stakeholder feedback. On May 29, 2018, CMS first announced our intention to implement the Review Choice Demonstration for Home Health Services through a PRA notice and sought initial public comments. On September 27, 2018, CMS published responses to initial comments and a subsequent PRA notice, and provided the public another opportunity to comment on CMS’ efforts to collect information on the revised demonstration. The second public comment period ended October 29, 2018. The published responses and additional information on the demonstration design are available here.

Page Last Modified:
03/26/2021 12:06 PM