Following CMS’ Review Choice Demonstration (RCD) implementation in Alabama on August 21, 2023, CMS has added guidance to aid in the process and has begun implementation in a new state.
Many hospitals are struggling to adapt to the significant changes, making it especially important for hospitals to have the necessary support to navigate RCD before, during and after implementation.
Get insight on current RCD challenges and strategies to help your hospital prepare for implementation from Lifepoint’s Jeanna Conder Best, Assistant VP of Quality for Acute rehabilitation units (ARUs) and inpatient rehabilitation facilities (IRFs), as well as the latest CMS guidance and timeline.
About Lifepoint and Jeanna
With over 30 years’ experience being a leader in post-acute and acute services, Lifepoint is equipped with the knowledge, expertise and resources to effectively navigate the complex regulatory landscape, including RCD implementation.
Jeanna holds over 25 years’ experience and has been a part of Lifepoint for over 17 years. Jeanna oversees the Clinical Documentation Integrity Team, helping provide documentation reviews and education as well appeal management and regulatory information to the field. She works closely with operations on a multitude of initiatives, such as RCD, to provide a collective approach as well as overall support and management.
What are some of the key challenges of RCD and how can hospitals overcome them?
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- Adapting to complex processes and ongoing changes.
Jeanna: RCD requires new procedures, an increased focus on documentation, and stricter adherence to guidelines. Compliance reviews occur every 6 months, putting pressure on timely and accurate record-keeping, especially with programs that utilize various EMRs, as well as those that maintain manual and digital records. Incomplete documentation leads to higher denial rates, costing hospitals money for services they can't bill for.
Having a dedicated rehabilitation partner to guide the facility through each review cycle and provide the education, tools and training can help ensure facilities are prepared, lowering the risk of denial. An experienced partner will also have a skilled Clinical Documentation Integrity team dedicated to helping partners through RCD.
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- Accurate assessment of compliance risk.
Jeanna: RCD offers pre- and post-payment review options, each with advantages and disadvantages. Hospitals must carefully consider their situation to select the best fit. If an option is not chosen by the mandated date, CMS will auto select the postpayment review process which could have negative impacts. Leveraging the support of a rehabilitation partner can help hospitals understand the pros and cons of each option and make a well-informed, strategic decision based on their specific needs.
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- Accessing specialized IRF care.
Jeanna: Identifying patients who qualify for inpatient rehabilitation facility (IRF) care is already challenging. RCD adds another layer of complexity, potentially leading to unnecessary denials due to fear of non-compliance, even for eligible patients. Limited rehabilitation access could cause a multitude of rehab-qualifying, medically complex patients to be denied IRF treatment and admitted to a lower level of post-acute care not equipped to take on their care needs.
A focused rehabilitation partner can help hospitals navigate the review process with confidence, ensuring appropriate access to care for their patients. This can prevent unnecessary denials and help ensure patients receive the critical rehabilitation they deserve.
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- Addressing unanswered questions.
Jeanna: It is anticipated that CMS will continue to change aspects of RCD as it is rolled out. There are and will continue to be many unknowns within the process overall due to the interpretations of the various Medicare Administrative Contractors. Without expert guidance, hospitals face the risk of errors and increased denials due to a lack of understanding of the evolving process as well as a lack of staff to maintain hospital operations and adhere to RCD guidelines.
Partnering with an RCD expert keeps hospitals informed of the latest updates and helps them adapt their processes accordingly without expending unnecessary staff and resources. This reduces the risk of errors and ensures continued compliance with the changing RCD program.
The right rehabilitation partner can stay ahead of the changing landscape and help relieve the burden of RCD – allowing hospitals to focus on what matters most: the patient.
Understanding Review Choice Demonstration
RCD is a program set forth by to protect Medicare funds from mis-payment and fraud. The ultimate goal is to improve compliance with Medicare program requirements and to make sure the right payments are made at the right time for the hospital-based ARUs or IRFs.
The duration of the RCD is five years and only applies to Medicare fee-for-service claims.
What are the claim options?1
Hospitals have two options for how claims will be reviewed as part of RCD.
Option 1: Pre-claim review. Submitters may submit a pre-claim review request at any time prior to the submission of the final claim. An unlimited number of resubmissions of the pre-claim review request are allowed prior to the submission of the final claim. The MAC will then communicate a decision to provisionally affirm or non-affirm via telephone within two business days. The MAC will provide a detailed decision letter within 10 business days of the review.
Option 2: Postpayment review. All claims are reviewed after final claims have been submitted and paid. This review follows current postpayment medical review processes (Additional Documentation Request: ADR). If CMS finds that the claim was not in compliance with Medicare requirements, the hospital may be required to refund the payment. This is the default selection if no initial review selection is made.
Current demonstration timeline
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- August 21, 2023: The first RCD began in Alabama.
- October 10, 2023: Following Alabama’s implementation, CMS provided an Inpatient Rehabilitation Facility (IRF) RCD Medical Review Checklist and an IRF RCD Beneficiary Fact Sheet in an effort to provide transparency in their medical review activities.
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- The Review Checklist is intended to compliment the Review Guidelines and help providers ensure the submission of required documentation.
- The Beneficiary Fact Sheet is intended to help provide additional explanation to beneficiaries regarding the decision letters received via mail during the IRF RCD.
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- June 17, 2024: RCD was expanded to IRFs in Pennsylvania.
- Dates TBD: The next states set to undergo RCD:
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- Texas
- California
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Looking for more information on RCD and which review option is the best fit for your hospital? Contact us today for a no-cost strategic consultation.
References:
- https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/review-choice-demonstration-inpatient-rehabilitation-facility-services
