Episode Transcript
[00:00:02] Speaker A: You're listening to Home Health Revealed, where the business of home health comes to life. Hosted by Hannah Vail, each episode brings real conversations with the leaders, innovators and experts shaping the future of the industry. From reimbursement and technology to leadership and growth. This is Home Health Revealed.
[00:00:20] Speaker B: Hey everybody. Welcome back to Home Health Revealed. And today we are going to be talking about RCD Review Choice Demonstration and we have a new state that's going to be joining, potentially joining. It's not official official yet, but California is next looking like to join our RCD states that are already in place. And so I want to talk about this announcement. Let me switch over to my screen here and the expansion of Review Choice Demonstration or rcd. So if you've been operating in Ohio, Illinois, Texas, Florida, North Carolina or Oklahoma, this isn't going to be a new conversation for you. And you have likely already experienced the additional documentation requirements, the submission processes and some of the operational changes that tend to come with rcd. But if you're in California, this is a conversation that you need to be having right now. It is November 4th. As of November 2nd, CMS announced plans to expand RCD into California. And the proposed Implementation date is January 18th of 2027 for the applicable billing periods, pending the approval of the revised information collection requirements.
But here is what's making this timing especially important. The selection window is scheduled to open November 16th and close December 16th. So you have a month that doesn't really leave agencies much time to understand their options or evaluate their current processes and prepare their team. So, so today what I want to do is break down what's happening, what agencies need to understand and how to get ahead of this rather than scrambling to catch up. Although I feel like we're going to be scrambling one way or another.
So here are the timelines and dates. Selection period is going to start November 16th, ends December 16th and then the demonstration would begin on January 18th of 2027.
So let's start with the basics of what Review Choice Demonstration is.
Review Choice demonstration is CMS's approach to evaluating whether home health agencies are meeting Medicare coverage and documentation requirements. The demonstration, since it's already live in some of the other states.
CMS has just announced that the demonstration will start to include all California home health agencies billing through Medicare Administrative Contract or MAX jurisdiction. Six was ngs. Now it's serviced by wellpoint, wellpoint Federal. But I also want to emphasize something here that this isn't a change to the Medicare Home Health Benefit itself. Agencies are still operating under the same underlying Medicare coverage requirements.
What changes is the level of scrutiny in the process through which agencies are going to demonstrate that their services meet those requirements.
And that distinction does matter. So you can have a patient who is appropriate for home health, a physician who has ordered services and a clinical team delivering excellent care.
But if the documentation doesn't adequately support that, the eligibility requirements, the skilled need, the homebound status and plan of care, the agency could could experience non affirmations.
They could experience delays and reimbursement challenges overall. So this is why rcd, it isn't simply a billing issue, it is a billing issue. But not only that, it's an operational issue really that touches intake, it touches clinical coding quality and revenue cycle. So it really encompasses all the pieces. That's why c important to have the right people in the room and in this conversation.
So what choices then will California agencies have?
Initially, agencies will choose between two options.
Option one is going to be basically option one is going to be pre claim review or pcr. And under this approach, the agency submits the required clinical documentation to the Medicare contractor before submitting the final claim. Let me I've already spelled this out today earlier in a blog post that just went live on the Health Fair website.
The contractor reviews the documentation and then issues a decision.
If the request is affirmed, the agency receives a utn, which stands for unique tracking number, which is then associated with the claim. This gives the agency an opportunity to identify the documentation concerns before moving into final billing. So it's kind of a foolproof way. It's almost like turning in your paper to your teacher for editing before you actually turn it in for a final grade. So hopefully that would help you when it comes to that final grade. That's option one. So option one, pre claim review. Option two is going to be post payment review. And this one's a little more risky. With this option, the agency submits its claims through the normal billing process, then the claims can be selected for review and then the agency will need to respond to an ADR or additional documentation request.
And this is important because reimbursement may initially occur, but then the agency still has to demonstrate that the services were covered and properly documented. And there's one thing I really want especially California agencies to understand.
If you don't make a selection during the designated selection period, CMS says that you will automatically default to the post payment review.
And if you have a strong opinion, I would not leave this to chance. If you really want to do the pre claim review, get that selection in place There are also some additional review choices available after agencies demonstrate compliance.
This is on down the road, but if you demonstrate compliance at at least a 90% or higher affirmation on your claim approval rate based on at least 10 submissions during the month, the applicable six month measurement period, you may qualify for a less intensive review option at that time. That's a good incentive to get the process right from the very beginning because it is going to cost some addition, some additional administrative time.
And we were looking today, I think CMS estimated that it would take an additional 340 hours by agency and I believe that was an annual, annual amount of additional workload. So this is definitely not to be taken lightly. And if you're an agency that staff is already spread thin, you're going to want to get everybody in the room, talk about who has capacity to do some of this stuff, look at potentially outsourcing if that's an option for you. Health Rev definitely helps. We do PCRs for states that are already in the RCD, but you may be able to do that in house. Just depends on how you want to arrange and organize your agency.
Let's talk about what I think are going to be some of the biggest challenges for agencies and that hands down is going to be getting documentation together.
And a pre claim review is not simply uploading a face to face note and assigned plan of care. The submission needs to tell a very complete, consistent story about why the patient qualifies for home health services. So at a high level agencies need to be prepared to provide the patient and medicare identification information, physician and agency identifying information, a qualifying face to face encounter for documentation.
And I want to come here while I'm reading through these and tell you that you can put in your name and email if you want to have a RCD pre claim review checklist. I'm just going to pull it up while I'm on here. So I guess if you look on here you can, you can see it right where it is on the website.
But this is going to give you what you would need during your pre claim review and it's going to give you some details here. But just again at a high level you're going to need the patient and medicare information, your physician and agency identifying information, the qualifying face to face encounter documentation, a signed plan of care and applicable certification documentation, documentation supporting the homebound status of the patient, documentation supporting the need for skilled nursing or for therapy and then any relevant orders, assessments and supporting clinical records.
And here's where I think agencies need to take a Closer look, it is not enough just to have the documents.
The documents have to support one another.
There has to be one cohesive story across your documentation. So does the primary diagnosis align with the reason for home health services?
Does the face to face encounter support the primary reason for the referral?
Does your clinical documentation actually demonstrate why the patient is home homebound?
Does the documentation explain why skilled services are necessary? Are the goals measurable? Are the interventions supported by the assessment? Are the physician orders complete and are they signed appropriately?
These are some additional questions. And these things really do matter. One of the biggest mistakes an agency can make is treating a PCR as a paperwork exercise instead of a documentation process quality exercise, because that's a very different approach.
The operational impact and what agencies may be underestimating. So I want to shift gears here for just a minute because I think there's a bigger conversation here.
When we talk about rcd, everyone naturally focuses on the documentation requirements. But what about the operational impact? Because they, they do go together. Who is responsible for pulling that documentation? Who's reviewing it for completeness?
Who is identifying missing signatures or conflicting information? Who's tracking those things down?
Who is submitting the request? Who is tracking the UTN number? Who is following up if something is non affirmed? Who's following up on those non affirmations? And what happens when the person responds responsible for the process is already managing a full workload?
They these become very big, small details. So for an agency with a high Medicare census, PCR can create a significant amount of additional work. And if the process isn't designed properly within your agency, you're going to see that workload spill into your clinical operations, your billing and your leadership. So I would encourage every California agency to start asking these questions. And if you're in a RCD state and you're still thinking through these processes, maybe things are not working well for you.
This is something to think through. And really, even if you're not California, this is Hannah's opinion, not CMS's anything opinion. But I think that RCD is going to continue trickling into the other states. But because it does cut down on waste and fraud, it does force you to have all your ducks in a row.
But if you're in California right now, I would start right away asking these three questions. One, do we have a clearly defined process for rcd?
Two, do we have the people and the capacity to management manage it? Do we need to hire for this dollar? Do we need to outsource for this? What is this going to look like?
Throw your options on the table.
Right now is also budget season. It's fall, but it's also budget season.
So it's probably the best time to be thinking through it.
Do we have the technology? This is the third one. Do we have the technology and the reporting to know where our submissions stand? Because you don't want your first real test of the process to happen when a claim is waiting for your payment.
And if you're an agency and you're thinking I'm going to choose post payment review, don't assume that that operational burden goes away. You are still going to need a very disciplined process for managing the ADRs gathering records, meeting deadlines and responding to review findings. And sometimes ADRs can can get into multiple levels if you are looking for a partner. This is my shameless plug for health Rep partners and why I believe that we can be a valuable resource for agencies navigating this transition.
This is not usually a salesy podcast and it isn't but I do want to offer this just for agencies who might be going into this and struggling. I want to give you some peace of mind because at Health Rev we work with home health and hospice agencies every day. We understand the intersection of clinical documentation, coding, OASIS billing and reimbursement. And what we've learned is that these functions do not operate in silos. So a coding issue can quickly become a reimbursement issue. An OASIS inconsistency can concern a missing physician signature can hold up your billing and a process that isn't create unnecessary work for everyone involved. If you want this pre claim review checklist you can download it yourself, go through this. I, I mean tweak it to make it work best for your agency. I give you full permission to do that and make sure that you have established a process for making sure you define the responsibilities submission checkpoints, accountability, making sure everyone across the agency understands what happens from the time the patient is admitted through that final claim submission.
Making sure that documentation and coding accuracy, our coding and OASIS experts help agencies identify those inconsistencies.
They are coding certified so so that they can put appropriate codes on that create that full clinical story and then whether your agency selects the pre claim review or the post payment review, the review process has to connect with billing. So for PCR that means coordinating documentation, readiness, submission, tracking UTNs and follow up getting that stuff on the front end. So you're going to have to be really hard nosed with those details, deadlines and submissions.
And then for post payment review that means you have to Have a process ready to manage the ADRs, collect the documentation, monitor those deadlines and then coordinate your responses.
One of the biggest challenges in RCD is knowing where those things stand, what has been submitted, what's pending, what's been affirmed, what needs attention, what's holding up billing.
I want to make something clear. Technology can help. But technology isn't the only answer. Technology can flag it, but experts have to continue making the decision. So having experienced people who understand what they're looking at, who can interpret the issue, who can work with your team to determine what happens next, that really can make make a really big difference.
So if I were sitting in the CEO or CFO seat of a California home health agency today, here is what I would be doing. First, I would confirm that my agency is included in the demonstration and identify every applicable ptan. You have to enroll every PTAN individually. Second, I would evaluate the two initial review choices.
I would not automatically assume that one is right for every agency.
I'd look at the agency's documentation quality, look at the internal staffing and the current billing processes, and then the ability to manage each review pathway.
Third, I would conduct a documentation readiness assessment, pull a sample of charts, look at the face to face documentation, review homebound support, evaluate skilled new need within those, check the plan of care, check the orders, the signatures, the OASIS consistency.
And then I would map out that workflow so I know who owns the process, where does the documentation come from, who reviews it, who submits it, assign a task and a person or in a department and then figure out who tracks those responses and who is responsible when someone something isn't affirmed.
And then finally, I would evaluate whether my current team has the capacity to absorb this additional responsibility without sacrificing other critical functions within the agency. People need to do their jobs to the best of their ability. And if it's going to impact caregiving or it's going to impact other pieces of the rev cycle, I would look at how I could outsource that or get some additional support there.
Because the last thing you want to do is to solve one compliance challenge by creating another operational problem.
And then remember that California agencies should pay particular attention to the state specific submission instructions. The current operational guidance does not allow California agencies to bundle multiple 30 day billing periods into one PCR request. So, so that's going to mean planning for submission workload, especially important per 30 days. Per 30 day billing period.
And then I want to leave you with one final thought.
RCD may be the reason you're evaluating your processes today. But truly improvements that you make should benefit your organization long after this demonstration begins.
Think about what happens when your documentation is more consistent, when your coding is more accurate, when your billing processes truly are more defined and more disciplined. I will say let's use that, let's use that D word more disciplined. And your team has better visibility into what's happening. Because you're not just preparing for a potential audit or a potential take back.
All of this is designed to mitigate fraud. It's also designed to help you build a stronger organization.
You're reducing avoidable rework in this structure. You're going to create some accountability systems. And also you're protecting your reimbursement. You're protecting your financial, your, your margin, really. And you're giving your leadership team better information to help make decisions. So at Health Rev, we talk a lot about the difference between traditional revenue cycle management and what we really call creating predictable revenue. Because ultimately it's not just about getting a claim out the door. It's more about understanding how the parts of your operations impact your revenue, impact your labor and all of the capacity that go into market margins. Be able to fuel your growth.
So when regulatory changes like RCD come along, those things become even more important.
So finishing up here to our California home health friends, the clock is ticking. Now's the time to start preparing.
CMS has announced the selection period beginning November 16, ending December 16.
This is still not a final decision. So you do have between now and then to give some feedback and then you don't have to figure everything out on your own. If you're unsure which review option makes sense, if you need help evaluating your documentation or if you're trying to determine how to build an RCD workflow, we I do have an sop. If you want to reach out to me on how we put together our workflow, I'm happy to have that conversation. I'm happy to share that with you. If you just want this RCD pre claim review checklist, it's available on our website.
And then if you want someone to partner with you, Health Rev has the expertise, we have the experience working with agencies in RCD states and then we are ready to help California agencies navigate what's ahead.
So reach out to our team. Let's get ahead of this together.
Again, thanks for joining me on this episode. Kind of a breaking news story and we will talk to you soon.
