Outsourcing Review Choice Demonstration Functions: One Solution to Staffing Struggles

The home health industry is facing a staffing crisis. According to a recent survey conducted by the National Association for Home Care and Hospice (NAHC), 80% of home health agencies are struggling to find qualified staff.  “Clinical staff are a valuable asset, often in short supply, in the home health agency. Taking those clinicians from performing back-office functions and back into patient care can maximize that resource and be a real game-changer for staffing.”, says Kim Wilkerson, RCD Manager at SimiTree.

This is having a negative impact on patient care, as agencies are forced to cut back on services or hire less experienced staff. How can agencies combat these rising issues in staffing? One opportunity to do just that is the outsourcing of some of your back-office staff. SimiTree offers a full array of RCD services to support states in the demonstration. 

The Review Choice Demonstration (RCD) is a program by the Centers for Medicare & Medicaid Services (CMS) in the United States. Initially rolled out in several states (Illinois, Ohio, Texas, Florida, and North Carolina), it’s meant to target and combat fraud in the industry and to reduce improper billing under Medicare’s home health benefit.  It is expected to be expanded to other states in the future.

There are three main options for selection under RCD:

  1. Choice #1- Pre-claim review of all claims

    The provider submits supporting documentation for review before claims are submitted for payment. Approved claims are then paid without further medical review. Non-affirmed decisions are afforded unlimited resubmissions. Your claims would not be pulled for ADRs on these claims. Agencies must maintain a 90% affirmation rate to remain under this option.

  2. Choice #2- Selective Postpayment review

    Claims are submitted and paid, then selected for retrospective review via ADR using
    a statistically valid random sample (SVRS) of claims.

  3. Choice #3 - Spot check review

    The provider is exempt from most post-payment reviews but must submit a small percentage of their claims for review. A 5% sample of claims is reviewed every six months via ADR.  Providers may remain in this option if they continue to show compliance with Medicare coverage rules and guidelines and maintain a 90% pass rate.

When your agency lacks the manpower and resources to fulfill the requirements of the Review Choice Demonstration, faces a pre-claim review backlog, or gets a big batch of ADR’s, outsourcing with SimiTree may well be the best solution. Outsourcing of RCD can be completely customized for the client.

“Typically, we assume the entire PCR process; assessing which claims need PCR, reviewing and submitting the documentation, and getting it ready to bill. But some agencies are more hands-on, and we only handle the submission component. Agencies should never be waiting on PCR to bill Medicare”, says Wilkerson.

Similarly, ADR submissions can involve a thorough review of the medical records and submission by the agency. Other agencies prefer delegating the process of preparing and submitting documentation for review to Palmetto.


The potential benefits of outsourcing this process include:

  • Time and money savings: Outsourcing PCR and ADR submissions can save agencies time and money. Agencies can free up their clinical staff to focus on patient care, while a third-party vendor handles the RCD functions. This can save agencies money on salaries, benefits, and training.
  • Improved accuracy and compliance: Is your agency looking to increase accuracy and ensure compliance? Outsourcing teams like SimiTree experts have experience with RCD, and they have the resources to ensure that submissions are accurate, compliant, and timely.
  • Freed-up clinical and clerical staff: Outsourcing RCD submissions can free up clinical staff to focus on patient care. Clinical staff are often the most valuable asset for home health agencies, and they should be focused on providing care to patients. Outsourcing RCD submissions can free up clinical staff to do what they do best, which is providing care to patients. Clerical staff can additionally be freed up to assist with important agency functions such as scheduling, medical records, and the like.

Not sure what is best for your agency? Schedule a complimentary one-on-one consultation today.

With a comprehensive team of experts like SimiTree, your team can be assured that all services are covered, including:

  • Full pre-claim submission
  • Operational assessment to identify compliance issues
  • Corrective plan with staff training
  • Consulting for selection cycle determination
  • ADR and appeals management

SimiTree RCD experts put all the experience gleaned in thousands upon thousands of pre-claim submissions and affirmations to work to your benefit. Costly agency resources and manpower requirements are eliminated, and providers receive assistance in catching up on RCD backlogs. SimiTree also helps assess, identify, and correct compliance issues through training and operational changes.

The SimiTree difference?

  • Expert and meticulous medical record review
  • Fast-tracking for claim submission
  • Consistently high affirmation rates
  • Feedback and guidance for improved compliance

Free up your staff to focus on what is important—taking care of your patients. We work seamlessly in the background, so there is virtually no need for your agency's daily involvement.

Learn more about how SimiTree can help your agency by submitting a contact form below.

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Let's work together to improve the health of your organization. At SimiTree, we balance financial expertise and clinical excellence to help our clients grow. How can we help you? Call us at 866.839.5471 or complete the form below.