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"Despite the COVID-19 public health emergency and the full resumption of the Medicare Review Choice Demonstration (RCD), medical review activities have been fully resumed. The triggering of a medical review poses an additional challenge to agency operations. Aside from the RCD, multiple Medicare, Medicare Advantage, and commercial insurance reviewers examine medical records for accuracy, including those that are newly billed and reopened claims. It is common for home health agencies to focus on survey compliance rather than reviewing their medical records from a compliance and payment perspective. Medical reviews, audits, or probes can pose great difficulties if you are selected to undergo one of these processes. Compliant clinical records are the key to success, whether it is through the RCD, the Unified Program Integrity Contractor (UPIC), the Recovery Audit Contractor (RAC), the Supplemental Medical Review Contractor (SMRC), or Comprehensive Error Rate Testing (CERT). The required rules and regulations should be incorporated into the content at the time of creation, not later. The presentation begins by outlining key coverage requirements from Medicare regulations and what they actually require. It then provides examples of how to reflect these in the home health record to address known denial reasons. These include both nursing and therapy medical necessity requirements. In linking what is actually needed with known denial reasons, it shows how proper documentation can prevent negative outcomes. This also applies to the RCD when the full record is not reviewed in pre-claim review or when it is reviewed under an Additional Documentation Request (ADR) option. This session provides a solid foundation for educating your staff to prevent future denials and audits. Your current staff can learn how to chart correctly, while new staff can learn from the actual regulations to start off right. The topics covered in this session can also be applied to Medicare Advantage medical reviews that are not subject to the RCD." Read more

While many home health providers dove into the Medicare Review Choice Demonstration (RCD) with trepidation, there are those who, after six months or more into the process, are finding that the documentation review program is not quite as bad as they thought it would be. So much so that these providers intend to continue participating in the Pre-Claim Review (PCR) process and never look back. This session will explore case studies to offer insights and lessons learned from providers who have successfully navigated the PCR process. Attendees will learn about the operational pitfalls to avoid and tips to help refine your organization's processes in order to improve your affirmation rate.  Speakers/Course Author - Lisa McClammy, BSN, RN, COS-C, HCS-D  Read more

Home health agencies have had to evolve to accommodate the Review Choice Demonstration (RCD), in particular, Pre-Claim Review. Likewise, an evolution of sorts has occurred in the interpretations and practices of the medical reviewers. We will examine the recent trends that have emerged, review some examples and learn how to ensure that the documentation your agency is submitting will affirm quickly, now and in the future.    Speakers/Course Authors - Kimberly Wilkerson, MBA, LPN, CHCE, COS-C, HCS-D  Read more

Some agencies are in first round selections, some are in second round selections, and some agencies are unsure of where to go from here. In this preconference session we will have a panel discussion on the things we have seen with submissions on PCR, how to decide which is the best level to choose on 2nd choice. Bring your questions to this informative session! Speakers/Course Authors - J'non Griffin, Kathy Harrison & Kim Wilkerson Read more

While the goal of submitting claims in the Review Choice Demonstration (RCD) project is to obtain provisional affirmation or payment, not all claims may end up achieving this status.  At that time the home health agency is faced with a choice of what to do with the claim: write it off as non-billable or appeal and seek payment. Even with the unlimited ability for resubmission under Pre-Claim Review (Choice 1), some claims will not achieve a provisional affirmation status. If the home health agency feels strongly for coverage, submitting the claim for final billing will generate an automatic denial. And for the Additional Development Request (ADR) prepayment (Choices 2, 5) and postpayment (Choice 4) options, an unfavorable decision only gives one option to obtain payment: appeal the denial. This presentation provides an overview of the RCD choices, agency options for a non-affirmed or denied claim, and preventive measures that minimize chances of an unfavorable RCD claim submission. This uses common denial reasons (applicable to the ADR choices) and non-affirmation reasons (for pre-claim reviews) and addresses how to prevent these for a smoother RCD experience. The process for filing appeals is also covered. Some areas covered include physician face-to-face (F2F) issues, certification deficiencies, and the most common medical necessity denials, including therapy documentation.   A thorough walk-through of F2F encounter requirements and how the F2F content links with PDGM payment and possible denials or non-affirmations is covered.  How these are applied to appeals for denied claims is presented.   Speakers/Course Authors - Joe Osentoski  Read more

Get your Medicare Review Choice Demonstration (RCD) questions answered! Join HCAF and Healthcare Provider Solutions' Melinda Gaboury for a deep dive into the RCD process.  Course Author: Melinda A. Gaboury, COS-C  Read more

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