Review Choice Demonstration (RCD) for Home Health: How to Raise Your Affirmation Rate

Review Choice Demonstration for home health changed how home health Medicare claims are reviewed in a group of states. For home health agencies, it created challenges in documenting and justifying the necessity for home health and the adequacy of documentation.

In addition to being able to demonstrate a good RCD affirmation rate to receive additional review options for each cycle, it is even harder to be efficient with documenting everything that needs to be there to achieve the required affirmation rate. In this document I will explain the Review Choice Demonstration for home health and why claims can be denied by Medicare. Also, how to better the quality of documentation to receive an affirmation and what steps home health agencies need to take to get ready for Medicare audits.

What Is the Review Choice Demonstration (RCD) for Home Health?

The Review Choice Demonstration, or RCD, is an optional home health program by CMS that gives Medicare HHAs a choice between submitting for either pre-claim or post-claim review to see if the services provided meet the Medicare coverage and documentation requirements.

This demonstration applies to the HHAs in Ohio, Oklahoma, North Carolina, Illinois, Florida, and Texas. With the latest update on June 1, 2024, CMS extended the program for an additional 5 years. HHAs are encouraged to periodically review the official RCD page to see if any of the information on the page has changed or if new requirements have been added.

Under the RCD for home health, agencies can initially select one of two review options:

• Pre-claim review: The agency submits supporting documentation before submitting the claim for payment.
• Postpayment review: The agency submits the claim first, and the Medicare Administrative Contractor (MAC) reviews supporting records after claim submission and payment processing.

After a six-month review cycle, agencies may qualify for additional options if they meet the required threshold and submit at least 10 requests or claims during the applicable cycle.

The purpose of home health RCD is to encourage compliance with Medicare rules and help ensure that claims are supported by appropriate records. It does not change the basic Medicare home health benefit or replace the need to meet coverage requirements.

What Is the RCD Affirmation Rate, and Why Does 90% Matter?

The rate of fully provisionally affirmed requests to the total number of pre-claim requests submitted during a period is called the RCD affirmation rate. In cases of postpayment review, claim approval rates are examined by CMS.

Agencies are required to maintain a claim or request approval rate of at least 90 percent over the preceding six months with a minimum of ten submissions for additional review options. Achieving a high rate in affirmation of home health requests does not mean agencies are exempt from adhering to Medicare guidelines. Documentation should be monitored to find gaps.

Top Reasons Home Health Claims Are Non-Affirmed

If documentation fails to meet the coverage guidelines for Medicare, a claim might be denied. Below are some typical issues:

1. Missing physician orders and certification

A claim may be denied if the necessary physician order and/or certification (initial or subsequent) for an episode is missing, or is incomplete or contradictory to the episode documentation.

2. Lack of or insufficient documentation of the required face to face (F2F) visit 

A claim might be denied if the required face to face (F2F) visit documentation does not support the need for home health services or if there is no documentation that the visit took place within the required time frame.

3. Weak or inadequate medical necessity documentation

The clinical notes may detail the patient's current condition but not provide evidence that skilled services (nursing or therapy) are required.

4. Clinical notes are contradictory

There may be variations among the different components of the clinical records, such as the Plan of Care (POC), the OASIS Assessment, and other physician documentation.

5. Errors and inconsistencies in coding and billing

Diagnosis codes might not be consistent with clinical record documentation, or details in a claim might contradict submitted clinical records.

6. Inadequate or unclear visit documentation. 

A patient’s need for services might not be apparent, or a patient's progress or response to services might be inadequately described in clinical documentation.

7. Incomplete submission packets. 

The necessary documentation for an RCD packet might not be submitted, or it might be poorly organized and unreadable.

Agencies should learn the common patterns and address them, rather than trying to improve a workflow around a single request after each denial for an RCD home health packet.

8 Practical Ways to Improve Your Home Health RCD Affirmation Rate

1. Confirm Patient Eligibility Before Submitting

You must confirm the patient meets the criteria for coverage under the home health benefit for Medicare. Ensure you have reviewed patient eligibility, including if they are homebound, as well as if they need skilled services and clinical supporting information. Patient eligibility should be apparent from the medical record. 

2. Improve Medical Necessity Documentation

Your clinical notes must clearly and comprehensively detail what skilled care was provided and why it was required. Phrases such as “stable” or “treatment continues” may not be adequate for your documentation of the need for skilled services. 

3. Inspect Face-to-Face Encounter Records and Physician Certification

You must ensure that face-to-face documentation, physician certification, and any subsequent recertifications, along with any other applicable orders, have all necessary dates and signatures, and contain all relevant statements. Medicare requirements regarding documentation supporting requests for home health services must be fully addressed. 

4. Check Consistency between OASIS and Visit Notes. 

You must also ensure that the OASIS assessment aligns with nursing and therapy documentation, the patient’s care plan, and other associated patient records.

5. Conduct Coding and Billing Quality Reviews

Check diagnosis codes, claim data, dates, and other billing information for consistency with the patient medical record. Confirm the coding is supported and complies with all current coding requirements. Professional home health coding services can provide an additional quality check on diagnosis codes and their alignment with the clinical record. 

6. Adopt a Standardized Pre-Claim Review Process

Establish a pre-claim review process that outlines who is responsible for each aspect of collecting, reviewing, and submitting records, including documentation, OASIS assessment, visit records, and claim details.

7. Track Reasons for Non-Affirmations

Analyze the trends in non-affirmations by assigning categories such as missing certification, medical necessity, face-to-face documentation, or coding discrepancies to the reasons behind the decisions.MShare the information and trends with all the staff members to help improve compliance, and update the checklist or introduce an additional quality check, as necessary.

8. Monitor Results and Educate Staff

Monitor and evaluate the results throughout the 6-month cycle. Record and assess the submission data, including the number of requests submitted, full affirmations, non-affirmations, and documentation that is yet to be resolved.

Home Health RCD Pre-Claim Review Checklist

A practical Home health RCD checklist helps teams confirm that the records are complete before submission. The exact documents required depend on the request and applicable Medicare requirements.

Use the following checklist as a starting point:

• Verify patient eligibility and applicable home health coverage requirements.
• Confirm that physician certification or recertification is complete when required.
• Check signed physician orders and the plan of care.
• Verify face-to-face encounter documentation and applicable timing requirements.
• Review OASIS assessments and relevant clinical findings.
• Confirm that nursing and therapy notes support the services requested.
• Check that the documentation supports medical necessity.
• Compare diagnosis codes and claim details with the clinical record.
• Resolve missing records, unclear dates, and inconsistencies.
• Confirm that all documents requested by the MAC are included.
• Check file readability, submission instructions, and required forms.
• Save submission confirmation and track the review outcome.

The RCD documentation requirements should always be checked against current CMS guidance and the contractor's instructions. A general checklist supports preparation but does not replace review of the specific request.

How Can Clinical Documentation Review and Coding QA Support RCD Readiness?

Conducting reviews of clinical documentation and coding quality assurance (QA) will identify weaknesses before clinical documentation is sent to the Fiscal Intermediary. Clinical documentation and billing must be consistent. Reviewers check to see if clinical documentation for billed services is present. A record of a physician’s order, a plan of care, and visit notes for clinical documentation must all support medical necessity and include documentation of face-to-face contact. The coding QA function verifies that ICD-9 codes support documented medical conditions. 

Clinical documentation and coding QA supports the home health Review Choice Demonstration and provides the ability for staff to identify and correct billing errors prior to submission. Findings from clinical documentation and coding QA can be utilized for both internal staff training and the development of internal protocols.

How Can Your Agency Monitor and Sustain a Strong RCD Affirmation Rate?

Maintaining a strong RCD affirmation rate requires ongoing monitoring, not just a final check before submission.

Agencies can establish a simple performance dashboard that tracks:

• Total requests or claims submitted during the cycle
• Full provisional affirmations or approved claims
• Non-affirmative decisions and denial reasons
• Missing documentation and coding issues
• Average time needed to prepare each submission
• Corrective actions and their results

The continuous maintenance of home health RCD requires agencies to adopt procedures, training, document record storage and compliance checks to Medicare regulations. This allows agencies to more consistently review documents and respond to requests.

How Gravita Oasis Review Helps Home Health Agencies Improve RCD Readiness?

Gravita Oasis Review supports home health agencies with documentation and revenue cycle workflows that can help prepare records for review.

Support may include:

• Clinical documentation review: Looking for things that're missing problems that don't make sense and places where the information isn't clear so that the right next steps can be taken.
• OASIS review: Making sure that the evaluations are complete and match the records from the patients care.
• Coding QA support: Assisting in finding differences between what was written about the patients health and what the diagnosis codes say.
• Medical billing support: Checking the billing details for any problems that might need fixing.
• Prior authorization support: Helping gather the needed documents and handling the steps required to get approvals.
• Data entry and workflow support: Helping keep records correct and making sure everything is easy to find for review.

These services can help agencies that are getting ready for the Review Choice Demonstration for home health by making sure the documentation is organized and by finding any problems, before the submission.

Conclusion: Make a 90% Affirmation Rate Your Baseline Under RCD

One result of CMS’s Review Choice Demonstration for Home Health is an emphasis on quality documentation in the Medicare claims review process. There is a benefit for an agency to put effort into developing an efficient process around eligibility, clinical record documentation, coding and submission packages, to avoid errors and the potential for a denied claim.

Agencies need to think beyond the 90% threshold. Agencies need to monitor all documentation and coding issues as well as monitor individual and collective performance, and track submission quality. Consistent RCD workflows, early problem detection, and maintaining readiness throughout every review cycle help to improve agency performance. 

FAQs on Review Choice Demonstration (RCD) for Home Health

Q1. What is an ADR in home health?

An ADR is a Medicare contractor's request for claim-supporting records. Agencies must submit the required documents by the stated deadline.

Q2. What affirmation rate do you need to reduce reviews under RCD?

Agencies generally need a 90% or higher rate and at least 10 requests or claims in the six-month cycle to qualify for additional review options.

Q3. What is the difference between pre-claim review and postpayment review?

Pre-claim review happens before claim submission for payment, while postpayment review occurs after the claim is submitted and processed.

Q4. How long does the Review Choice Demonstration last?

CMS extended the demonstration for five years starting June 1, 2024. Check the CMS website for current updates.

Q5. How often is the RCD affirmation rate calculated?

CMS evaluates affirmation or claim approval results over six-month review cycles.

Q6. How can I appeal or resubmit a non-affirmed pre-claim request?

A non-affirmed request cannot be directly appealed. Agencies can resubmit supporting documents or appeal a claim denial through the applicable Medicare process.