< Back to Association News

RCD CLAIM APPROVAL RATE CALCULATIONS

By Beth Foster, RN, BA, CPHQ, CEHCH

 

Palmetto GBA has received questions regarding the claim approval rate calculation results while in the RCD.

Palmetto responded with – Please be reminded:

  1. There are NO recalculations for the RCD end of cycle results.
    OUR TAKE: This means the 6 month cycle results cannot be appealed or changed.
  2. Appeals and partial payments do not count towards your claim approval rate.
    OUR TAKE: Good to know!
  3. All initial decisions do apply toward your claim approval rate.
    OUR TAKE: Good to know! In PCR agencies can submit as many times as they want to until a final affirmation is received. In this case all of the non-affirmations do not count.
  4. The RCD ADR process is different from the TPE process. During the RCD ADR review process:
  • There are no easily curable telephone calls, and
  • The Medical Reviewer does not contact the HHA for missing documents
    OUR TAKE: Also, Good to know for the home health agencies (HHAs) that chose the postpayment review option that they need to respond to the ADR request with the correct documentation submitted the first time. HHAs will receive ADR requests for every claim submitted, which should be at least every 30 day pay period.

OUR TAKE: HHAs that selected postpayment review option and after the first 6 months received an approval rate of 90% or greater (based on a 10 request/claim minimum), might consider selecting from one of the three subsequent review choices:
• Choice 1: Pre-Claim Review (less paper work), or
• Choice 4: Selective Postpayment Review (more paper work)
(HHAs that select this choice will remain in this choice for the duration of the demonstration regardless of their claim approval rate), or
• Choice 5: Spot Check Review (Palmetto will select a random sample of 5% of a HHA’s submitted claims, based on their previous 6 months’ claim volume, for pre- payment review)

REMINDER: Ohio’s initial 6 month PCR/POSTPAYMENT review goes through March 31, 2020. Palmetto will spend April calculating the approval rates for each HHA. In May HHAs will be making a new option choice, if they want too.

Additional resources can be found on Palmetto’s website: www.palmettogba.com/rcd or on the CMS website.

If you need assistance, please contact Palmetto GBA’s Jurisdiction M Provider Contact Center at 855–696–0705.

HelpDesk Question of the Week

 

HOSPICE:  Recertification

Question: We have a pt with  a third certification  date starting 1/3   Our medical director did the face to face on 12/12 and wrote the attestation on 1/3 is this permissible to have the attestation signed on the first day of the new certification period?

Answer: Here is the guidance on recertification from the Hospice Medicare Benefit Policy Manual Chapter 9:
For the subsequent periods, recertifications may be completed up to 15 days before the next benefit period begins.  For subsequent periods, the hospice must obtain, no later than 2 calendar days after the first day of each period, a written certification statement from the medical director of the hospice or the physician member of the hospice’s IDG.  If the hospice cannot obtain written certification within 2 calendar days, it must obtain oral certification within 2 calendar days.  When making an oral certification, the certifying physician(s) should state that the patient is terminally ill, with a prognosis of 6 months or less.  Because oral certifications are an interim step sometimes needed while all the necessary documentation for the written certification is gathered, it is not necessary for the physician to sign the oral certification.  Hospice staff must make an appropriate entry in the patient’s medical record as soon as they receive an oral certification.