By Patrick Filbin, Home Health Care News (June 28, 2023)

The mission of all home health agencies is to improve patient satisfaction and clinical outcomes, at least in part.

Some of those providers do not feel like the Review Choice Demonstration (RCD) is helping in either of those areas.

“With the extra burden that you have that comes with RCD, it really hasn’t changed or caught these fraudulent actors in our industry,” Janice Riggins, chief clinical officer at VitalCaring, told Home Health Care News. “It really hasn’t improved patient care, it really hasn’t improved outcomes. It’s just that: an ongoing administrative burden.”

The Dallas-based VitalCaring is a newer home health company helmed by industry titan April Anthony. Its network includes over 70 locations across six states.

Riggins is a veteran of the home health space but has been thrust into RCD given the VitalCaring’s footprint in Texas and Florida, two of the five states where the Centers for Medicare & Medicaid Services (CMS) demonstration is active.

Generally, RCD requires home health care providers to submit claims documentation earlier on in the care process and is meant to target and combat fraud in the industry.

CMS’ goal in RCD is to reduce improper billing under Medicare’s home health benefit.

In 2017, lawmakers successfully blocked the expansion of the Pre-Claim Review Demonstration (PCRD) — the precursor to RCD. The original iteration got off to a rocky start in Illinois, with providers and associations complaining of administrative burden, compliance costs, and high non-affirmation rates.

A few years later, RCD was introduced in five states: Illinois, Ohio, Texas, North Carolina, and Florida. CMS suspended the demonstration in late March of 2020 due to the COVID-19 crisis, but soon after announced that it would resume in August, much to the chagrin of providers in those states.

A year later, CMS made a major change to the way billing was processed which was a reprieve for providers. Despite some of the changes — and the fact that providers in RCD states have had years of experience — there are still significant gripes from providers.

“That increased burden and costs associated with RCD is on top of our labor challenges and our workforce challenges,” Riggins said. “We really need to take a look at all the administrative burdens that we’re placing on the home health industry. We should be applying more of our resources in how we truly improve our quality of care, efficiencies, and optimization of our clinicians.”

RCD Positives

There are also industry advocates that see benefits in the Review Choice Demonstration.

For example, it keeps agencies on their toes and makes sure their ducks are in a row when filing claims.

“Many of the agencies that do like it, what they like about it is that, instead of having to deal with an [additional documentation request] on the back end that they may not be prepared for, they can use the pre-claim review option so they have an idea of what is coming,” Katie Wehri, director of home care and hospice regulatory affairs at the National Association for Home Care & Hospice (NAHC), told HHCN. “That way they know how long it will take to pull the information together and what resources they will need to commit.”

Wehri said it’s important for those providers to make sure their staff is familiar with what the requirements are, and to know what types of records need to be requested.

“Once you start doing that consistently, it’s easier to move to a less-frequent review,” Wehri said.

In the first year of VitalCaring’s RCD process, the company was part of Option 1, which includes the pre-claim review process and a lot of upfront work.

In the RCD, agencies have three initial review choices to choose from and then three subsequent review choices to choose from.

There are pros and cons to each option. After a year, Riggins realized VitalCaring was well above the 90th percentile in Medicare billing.

“When we started analyzing that, it came to our attention that, for us, it made more sense to go at a little bit more risk and really try our hand at Option 5,” Riggins said. “So far, in the first six months of that option, we did quite well and are in the 96th percentile. But regardless of which option you choose, there’s still that administrative burden. But the pre-claim really puts more of that 100% burden on you trying to obtain that affirmation.”

Like anything, time and familiarity usually lead to more comfortability with regulations and processes like RCD.

That’s largely been the case in Florida.

“It seems like the providers that have been in the demonstration — either from the beginning or for a good portion of time since the demonstration started — have got their processes in place and things are working well,” Patti Heid, director of clinical and regulatory affairs with the Home Care Association of Florida (HCAF), told HHCN. “For them, if they run into an issue, it’s typically a one-off.”

National Expansion Next?

What comes next in RCD is tough to predict.

“We don’t really have anything from CMS to tell us what the results of the RCD are and we probably won’t see that until after the demonstration is complete,” Wehri said. “I don’t know what’s going to happen as far as expanding it beyond. To be honest with you, I would not be surprised if additional states were involved, or there was some sort of expansion, but we really don’t have any indication from CMS that that will happen.”

Providers across the country should at least be considering RCD, and doing what they can to prepare for a potential expansion.

“We got pushed back and Illinois was the one who took the brunt of this,” Heid said. “Even though we got a reprieve, we hammered home to our providers, ‘Don’t wait until it becomes mandatory. Start preparing now, start your education, and start getting your processes in place.’ The more preparation you do up front, potentially, the shorter the learning curve will be for you as you enter the process.”

Summed up in one sentence, Riggins thinks in an industry where resources are scarce, providers would be better suited investing in other areas.

“I just feel like we’re applying the resources in the wrong bucket,” he said.