Since the pause of the Pre-Claim Review Demonstration in April 2017, CMS has been working to develop an alternative called the Review Choice Demonstration. It states that this new demonstration will, “offer more flexibility and choice for providers, as well as risk-based changes to reward providers who show compliance with Medicare home health policies.” Participation is not mandatory. However, home health agencies that choose not to participate will be penalized through a 25% reduction to payments.

What is the Review Choice Demonstration?

The proposed Review Choice Demonstration will give home health agencies in demonstration states (see below) a choice of three options: pre-claim review, postpayment review, or minimal postpayment review. Once an agency selects a review method, it will be limited to that method moving forward.

Pre-Claim Review

With this method, home health agencies will request provisional affirmation of coverage before submitting final claims. The submission and response process can occur after services have been provided. According to CMS, “Pre-claim review helps make sure that applicable coverage, payment, and coding rules are met before the final claim is submitted.” Pre-claim review will be required for every episode of care, but agencies can submit requests for multiple episodes of care at once.

Agencies that choose pre-claim review during the Review Choice Demonstration will be subject to this method until it reaches the target 90% affirmation or claim approval rate. Once the target is achieved, an agency may choose to stop submitting claims for review. However, the agency will be subject to spot checks to prove ongoing compliance.

Postpayment Review

Postpayment review will operate according to normal claim processes. Medicare Administrative Contractors will conduct reviews for all claims submitted during a six-month period to verify compliance. Postpayment review will be required for each episode of care, but unlike pre-claim review, agencies cannot get approval for multiple episodes at one time.

Agencies that choose postpayment review must continue with this method until they reach the target 90% affirmation or claim approval rate. Once the target is achieved, an agency can choose to stop submitting claims for review, but it will be subject to spot checks to ensure ongoing compliance.

Minimal Postpayment Review

Home health agencies that choose not to participate in either the pre-claim or postpayment review can still submit claims. However, all payments will be reduced by 25% and claims may be subject to review by a Recovery Audit Contractor.

What states are included in the Review Choice Demonstration?

CMS proposes to start the Review Choice Demonstration in Illinois, Ohio, North Carolina, Florida, and Texas with the option to expand to other states in the Palmetto/JM jurisdiction.

When does the Review Choice Demonstration go into effect and how long will it last?

The Review Choice Demonstration is proposed to begin on December 10, 2018 in Illinois and will last five years.

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