The Review Choice Demonstration (RCD) was a home health boogeyman when the program was announced in 2018, with industry stakeholders fearing it would cause major disruptions.

Fast forward some years later and home health providers have, mostly, gotten the hang of RCD requirements – and some are even advocating for its expansion.

Broadly, RCD is a program implemented by the Centers for Medicare and Medicaid Services (CMS) with a goal of decreasing improper billing from home health providers and addressing fraud in the industry.

Currently, home health providers in Illinois, Ohio, Texas, North Carolina, Florida and Oklahoma are subject to RCD. These states are within the jurisdiction of the Medicare Administrative Contractor (MAC) Palmetto GBA.

Under the program, home health providers have the choice of either pre-claim review or post-claim review. Providers that do not make an active choice automatically are grouped into the second category.

“All the data says that most people picked the pre-claim review, and that gives you the option to submit your claims as many times as you want,” Katy Barnett, director of home care and hospice operations and policy at LeadingAge, told Home Health Care News. “If you get a correction back from Palmetto, saying ‘This is wrong and this is wrong,’ you have as many chances as you want to correct it. On the post-claims review, you’re looking at absolutely every claim that you’ve submitted, and you have ADRs for each of those claims.”

Providers should aim to reach a 90% clearance threshold, meaning that this percentage of their claims is clean.

RCD has a history that spans several years in the industry. It was originally announced in 2018 as a revamped version of the Pre-Claim Review Demonstration (PCRD), which was rolled out in Illinois in 2016 and concluded in 2017, after lawmakers blocked its expansion. At the time, providers were vocal about how PCRD created administrative burden and compliance costs.

In March 2020, RCD was suspended as a response to the COVID-19 pandemic. It resumed in August 2020. Last year, CMS announced a five-year extension of RCD.

Industry opinions

In recent years, Mary Carr, vice president of regulatory affairs at the National Alliance for Care at Home (The Alliance), has seen a shift in sentiment regarding RCD.

“When agencies first hear they’re going to go on it, they panic because it does take a lot to get started on this,” she told HHCN. “They’re going through a 100% review on one end, either after payment or prior to submitting the claim. But once they get in a rhythm and they start to get it going, we’ve actually heard that they like it.”

Indeed, companies like AccentCare have been vocal in their support for RCD, even calling for further expansion.

“Given mounting evidence of aberrant behavior in California, AccentCare recommended in its CY 2026 comment letter that CMS expand RCD to California and supports nationwide expansion,” Stacey Smith, vice president of public affairs at AccentCare, told HHCN in an email. “We have also advocated to CMS and Congress that pre-claim review should be the only option, since post-payment review continues to rely on a “pay-and-chase” fraud prevention model.”

Carr noted that the industry likes RCD because the program process ensures that providers are paid.

“It’s not, two months from now, a year from now, they’re going to come back and review a claim and deny it,” she said. “With this demonstration, if they affirm your submission, your record, your claims, then it’s pretty much guaranteed that you are going to get paid for that.”

That said, the providers experiencing the most trouble are typically those that choose the post-claim review option, or end up in this cohort by default.

“We’ve heard from members that are in that bucket, in that choice, that it’s really hard to get to that 90% threshold,” Barnett said.

LiveWell Partners first entered RCD through its acquisition of two home health companies operating in Illinois and Ohio.

The company is part of the pre-claim review group at both locations, according to Kevin LeGrand, vice president of revenue cycle management at LiveWell Partners.

“For the most part, I feel like it’s going pretty well,” he told HHCN. “We have pretty high affirmation rates at both of those locations, even in Ohio, which has different requirements, or is a little more strict on their reviewing than Illinois tends to be.”

LiveWell Partners is a home health and hospice provider headquartered in St. Louis. The company currently operates in St. Louis, Kansas City, Wichita, Kansas, Detroit and Cincinnati.

RCD strategies

One of the main ways the company stays compliant with RCD requirements is through its electronic medical record (EMR).

“We actually have edits put in place within our EMR that are flagging the Medicare claims for both those states that we have to compile the pre-claim review data on,” LeGrand said.

The company also has a staff member on its billing team who is responsible for gathering this information and uploading it to the provider portal. The employee views notes, visit data and assessments before uploading them to the RCD portal.

LeGrand isn’t surprised that many of his industry peers, similar to LiveWell Partners, have chosen pre-claim review, especially in this current home health environment.

“If you did post-claim review … you’re at a higher risk of losing revenue,” he said. “In this industry, there’s already a proposed massive cut in the books for next year. Any chance that you have to prevent the possibility of lost revenue is huge, especially at smaller locations like we have.”

LeGrand believes that the companies seeing the most success with RCD are those that have not siloed off this process.

“You have to make sure that it’s not just your revenue cycle team and or the person who is submitting this is paying attention to it,” he said. “You want to make sure your orders team, your clinical team, that everybody’s in lockstep when they are working these Medicare patients to make sure everything is right, is documented appropriately the first time, so when we do submit it, you are getting that positive affirmation.”

Barnett stated that CMS is largely achieving what it set out to do with RCD. However, she has identified some room for improvement.

“Overall, there’s been a pretty decent trend of decrease in spending, though it’s slowed down over the years,” she said. “When it was first implemented, there was a really deep decrease, and now it’s kind of leveled out, but still decreasing. I think one of the barriers to this program is that there are 12 more states that aren’t part of the demonstration in Palmetto’s jurisdiction. This doesn’t necessarily capture all the aberrant billing areas around the country. We have been very vocal about our concerns with billing practices in California.”

Unlike the 12 states that Barnett referenced, California isn’t under Palmetto’s jurisdiction. It falls under the jurisdiction of National Government Services (NGS). If CMS were to implement RCD in California, it would need to bring on NGS as an independent contractor for this program. Barnett believes that this is unlikely.

“While the program has decreased spending, overall, and hopefully made it easier for providers to submit documentation and get that pre-claim process under their belt, it may not be hitting the real spots of trouble in the home health program,” she said.