RCD Compliance: Essential Guidelines for Home Health Agencies

Medicare’s Review Choice Demonstration (RCD) fundamentally changes the landscape of home health reimbursement—a shift that directly impacts how agencies operate, document, and receive payment for their services. With CMS extending the program through 2029, mastering RCD compliance has become essential for agencies focused on maintaining financial health while delivering quality patient care.

Currently active in Illinois, Ohio, Texas, North Carolina, Florida, and Oklahoma, RCD compliance requires agencies to adapt their operational processes to meet stringent documentation and submission requirements. The program’s latest evolution, announced in May 2024, streamlines agency choices by removing the minimal review option—leaving agencies to select between pre-claim review and post-payment review to demonstrate Medicare compliance.

Agency leaders navigating these requirements understand that strong RCD compliance measures create the foundation for operational excellence and sustainable growth. Strategic process implementation drives efficiency, ensures financial stability, and maintains uninterrupted patient care delivery.

Key Elements of RCD Compliance

Home health agencies must grasp several critical aspects of RCD compliance to successfully navigate this demonstration program. These fundamental elements shape the program’s implementation and impact:

Program Purpose and Objectives

Ensure accurate Medicare payments for home health services
Reduce improper billing practices and payment errors
Strengthen documentation standards across participating agencies
Protect Medicare Trust Fund resources
Decrease the volume of Medicare appeals

Key Program Elements

Agencies must choose between specific review options
Documentation requirements remain consistent with existing Medicare standards
Reviews occur either before claim submission or after payment
Performance monitoring determines future review options
Compliance thresholds impact long-term participation requirements

Current Implementation Status

The demonstration continues to operate in six states, with specific requirements for each:

Illinois (implemented June 2019)
Ohio (implemented September 2019)
Texas (implemented March 2020)
North Carolina (full implementation September 2021)
Florida (full implementation September 2021)
Oklahoma (implemented December 2023)

This structured approach to Medicare compliance provides agencies with clear guidelines while maintaining flexibility in their chosen review paths. Home health leaders who understand these foundational elements position their agencies for successful program participation and sustainable Medicare reimbursement.

RCD Review Options and Selection Process

The Review Choice Demonstration offers home health agencies flexible paths to demonstrate Medicare compliance, each with distinct advantages and operational considerations. The program structure includes both initial selections and performance-based options:

Home health agencies initially select from two primary review paths:

Pre-claim Review: Agencies submit documentation before final claim submission, receiving advance certainty about payment status. This option demands meticulous upfront documentation but offers clearer reimbursement timelines and a potential reduction in future review requirements.
Postpayment Review: Agencies follow standard claim submission timing with reviews conducted after payment. While this maintains normal billing workflows, agencies must excel at documentation maintenance and prepare for possible payment recoupment.

After completing a six-month review period, high-performing agencies unlock additional options. Those achieving a 90% or higher affirmation rate (with a minimum of 10 submissions) can choose:

Continued pre-claim review participation
Selective post-payment review
Spot check review process—involving random review of just 5% of claims

Each path requires careful evaluation based on your agency’s unique operational capabilities. Pre-claim review offers predictability but demands more upfront work. Postpayment review maintains familiar workflows but introduces potential financial uncertainty. The spot-check option rewards consistent performers with reduced oversight.

Agency leadership teams should assess their staffing resources, documentation processes, and cash flow requirements when selecting their RCD path. The right choice aligns with your agency’s operational strengths while supporting sustainable growth and compliance excellence.

Essential RCD Documentation Guidelines

How does your agency ensure Medicare reimbursement under RCD? The answer lies in precise documentation and efficient submission processes. Understanding these requirements creates the foundation for consistent claim affirmation:

Core Documentation Requirements

Your submission package must include evidence of:

Patient’s homebound status with specific examples
Face-to-face encounters between patients and physicians
Detailed physician certifications and orders
Clear demonstration of skilled care necessity
Comprehensive plan of care
Complete OASIS assessments
Visit notes that support all provided services

Understanding the Submission Process

The Medicare Administrative Contractor (MAC)—Palmetto GBA for RCD states—offers multiple submission channels to fit your agency’s workflow:

Palmetto GBA’s eServices portal
Electronic submission of medical documentation (esMD)
Secure fax submission
Mail submission options

Timing matters—Palmetto GBA aims to respond to initial requests within 10 business days. If your submission needs revision, expect up to 20 business days for resubmission review. Meeting these timelines requires organized, complete documentation packages from the start.

Documentation Excellence Strategies

Success depends on systematic approaches:

Standardized documentation templates that capture all required elements
Multi-level review processes before submission
Clear internal timelines for documentation completion
Submission tracking systems to monitor status
Structured protocols for handling non-affirmed decisions

Documentation quality directly impacts your agency’s financial health and patient care delivery. Agency leaders who prioritize thorough documentation practices see higher affirmation rates and smoother reimbursement cycles, creating a stable foundation for sustainable growth.

Strategic Pathways to RCD Success

Creating a strong RCD compliance program requires more than just documentation—it demands a comprehensive approach that aligns your entire team around clear processes and goals. Here are the essential strategies that drive successful RCD participation:

Clear Documentation Workflows: Your team needs established processes for capturing, reviewing, and submitting documentation at every stage of patient care. This creates consistency and reduces submission errors.
Proactive Timeline Management: Set internal deadlines well ahead of MAC requirements to allow time for a thorough review and any necessary corrections. This buffer protects your reimbursement cycle.
Staff Role Definition: Every team member should understand their specific responsibilities in the RCD process, from initial documentation to final submission.
Quality Control Systems: Regular internal audits help identify documentation gaps before they become claim issues. This preventive approach maintains high affirmation rates.
Performance Monitoring: Track your affirmation rates, common rejection reasons, and submission patterns to identify areas for improvement and training needs.
Training Programs: Develop comprehensive education programs that keep your team current on RCD requirements and best practices. Regular updates maintain competency.
Communication Protocols: Create clear channels for sharing updates, addressing challenges, and celebrating successes across your organization.
Response Planning: Establish structured protocols for handling non-affirmed decisions quickly and effectively to maintain steady cash flow.
Technology Integration: Leverage available tools and systems to streamline documentation and submission processes while reducing manual errors.

At SimiTree, our industry experts guide agencies through these strategic elements, helping align business operations with care delivery for optimal RCD compliance. Our proven track record of transforming home health agencies’ RCD processes demonstrates the power of experienced support.

Understanding RCD’s Impact on Agency Operations

The transition to RCD compliance significantly reshapes daily operations, touching every aspect of your agency’s workflow, from clinical documentation to financial planning. Success requires thoughtful adaptation of existing processes while maintaining a focus on quality patient care delivery.

Financial considerations create the foundation for effective RCD participation. Agencies must plan for potential changes in cash flow timing, especially when selecting pre-claim review paths. This includes allocating resources for enhanced documentation processes, investing in staff training programs, and potentially updating technology systems to support streamlined submission processes.

Clinical teams face the most immediate operational changes, needing to integrate stringent documentation requirements into their daily routines. Real-time documentation completion becomes critical, supported by structured internal review processes and clear communication channels between field staff and administrative teams.

Key performance indicators help track your agency’s RCD success:

Affirmation rates across all submission types
Average documentation completion timeframes
Length of submission cycles from start to finish
Frequency of resubmission requirements
Staff productivity levels alongside documentation quality
Cash flow patterns under chosen review paths

Strong operational planning creates stability during RCD implementation. Strategic process adjustments, combined with consistent monitoring of these key metrics, allow agencies to maintain smooth workflows while meeting all program requirements. The goal remains clear: supporting quality patient care while ensuring appropriate reimbursement through proven compliance measures.

SimiTree: Your Partner in RCD Excellence

Home health agencies navigating RCD compliance benefit from comprehensive support across clinical, financial, and operational domains. SimiTree’s integrated approach combines deep expertise in three critical areas that drive RCD success:

Strategic Consulting Services: Our experts develop customized roadmaps for RCD implementation, streamlining processes and optimizing workflows for maximum efficiency. From initial choice selection through ongoing compliance monitoring, we guide your team through every step of the RCD journey.
Compliance & Regulatory Risk Management: Our team ensures your agency maintains strong documentation practices while meeting all Medicare requirements. We stay current with evolving RCD guidelines, helping you adapt quickly to program changes and maintain high affirmation rates.
Revenue Cycle Management: Our billing expertise complements these offerings by optimizing submission processes for consistent reimbursement. We understand how different review choices impact cash flow and help establish sustainable billing practices under RCD.
Coding & OASIS Services: Our expert team performs over 600,000 reviews annually with 98%+ accuracy, ensuring precise documentation that supports RCD compliance. Our 48-hour turnaround time helps maintain smooth operational workflows while maximizing reimbursement potential.

With over 16,000 agencies served and more than 450 industry experts, SimiTree delivers the comprehensive support needed for sustainable RCD compliance. Our proven track record of aligning business operations with care delivery helps agencies transform RCD requirements from operational challenges into opportunities for excellence.

Ready to strengthen your RCD compliance program? Contact our team today to learn how SimiTree can support your agency’s success.

Frequently Asked Questions

What is RCD compliance in home health care?

RCD (Review Choice Demonstration) compliance refers to a Medicare program that requires home health agencies to demonstrate their compliance with Medicare rules through either pre-claim or post-payment review processes. The program currently operates in six states: Illinois, Ohio, Texas, North Carolina, Florida, and Oklahoma. Agencies must meet specific documentation requirements and maintain high affirmation rates to demonstrate successful compliance.

How does RCD pre-claim review work?

Pre-claim review involves submitting documentation to Palmetto GBA before filing a final claim for Medicare reimbursement. Agencies receive a decision within 10 business days for initial submissions and 20 days for resubmissions. Successful pre-claim reviews result in provisional affirmation, allowing agencies to submit claims with confidence of payment.

What are the RCD choice options for home health agencies?

Home health agencies initially choose between pre-claim review and post-payment review options. After maintaining a 90% affirmation rate over six months (with a minimum of 10 submissions), agencies can select from additional options, including selective post-payment review and spot check review. Each option offers different benefits depending on an agency’s operational capabilities and resources.

What documentation is required for RCD compliance?

RCD compliance requires comprehensive documentation including proof of homebound status, face-to-face encounter records, physician certifications, skilled care necessity evidence, complete plan of care, OASIS assessments, and detailed visit notes. All documentation must demonstrate clear medical necessity and comply with Medicare coverage requirements. Agencies must submit this documentation through approved channels, including Palmetto GBA’s eServices portal or esMD.