RCD: Why Medicare’s New ‘Choice’ Means More Paperwork for Physicians

What is the Review Choice Demonstration?

RCD requires providers—specifically Home Health Agencies (HHAs) and Inpatient Rehabilitation Facilities (IRFs)—to choose how their Medicare claims will be reviewed. The goal is to ensure that patients truly meet the "reasonable and necessary" criteria before or shortly after payment is issued.

Providers in participating states (including Illinois, Ohio, Texas, North Carolina, Florida, Oklahoma, Alabama, and Pennsylvania) typically choose between:

• Pre-Claim Review: Documentation is submitted and "affirmed" by Medicare before the final claim is even filed.

• Post-Payment Review: Claims are paid first, but 100% of them are subsequently audited, with the risk of payment recoupment.

How It Affects the Physician

While physicians are not the ones selecting the "review choice," they are the primary source of the documentation that determines whether a claim is paid. Here is how RCD changes a physician's daily workflow:

1. Increased Scrutiny on "Face-to-Face" Encounters

Under RCD, Medicare reviewers meticulously check the Face-to-Face (F2F) encounter notes. For a physician, this means a standard brief note is often no longer sufficient. You must explicitly document:

• The clinical reason the patient is homebound.

• Why the patient requires "skilled" care (e.g., specific nursing or therapy needs) rather than just general assistance.

• How the encounter directly relates to the primary reason for home health or rehab services.

2. Heightened "Signature" Urgency

Because agencies opting for Pre-Claim Review cannot submit their claims without an affirmed tracking number, they are under immense pressure to get physician signatures quickly. Physicians may experience a higher volume of "urgent" requests to sign:

• Plans of Care (Form 485).

• Verbal orders and supplemental certifications.

• Medical necessity clarifications.

3. Documentation "Loopbacks"

If an HHA or IRF receives a "non-affirmation" (a rejection) during the pre-claim process, they must fix the documentation and resubmit. This often results in the agency circling back to the physician to ask for more specific language or additional clinical details to satisfy the auditor's requirements.

4. Potential Barriers to Patient Access

In some cases, the "fear of denial" caused by RCD can make facilities more hesitant to admit complex patients. Physicians may find it more difficult to transition patients from acute care to home health or rehab if the documentation doesn't perfectly align with CMS’s "strict interpretation" of medical necessity from day one.

Summary for the Practitioner

Impact Area

Change Under RCD

Documentation

Must be more granular; "boilerplate" templates are often rejected.

Timeliness

Faster turnaround required for signatures to avoid agency cash-flow issues.

Communication

Increased "back-and-forth" with agency clinical managers for clarifications.

Liability

Accurate documentation is the only shield against payment recoupment (audits).