Home Health Review Choice Demonstration: CMS Affirmed 97% of Pre-Claim Requests — and Overturned 51.6% of Appeals

5 days ago

6 min read

CMS reviewed 1,898,522 home health claims under the Review Choice Demonstration in fiscal year 2024, denied 66,096 of them, and then overturned 51.6% of the denials that agencies actually bothered to appeal. Only 4,695 of those 66,096 denials were appealed at all — about 7%. CMS states plainly in its own statistics release that the most common reason for an appeal overturn is the submission of additional documentation that was not provided during the initial review. Read that sentence twice: more than half of the denials agencies fought were not coverage failures. They were paperwork-timing failures, and agencies that never appealed simply ate them. Here is what the FY 2024 numbers show and what to do with them.

Key Takeaways

The RCD operates in six states: Illinois, Ohio, Texas, North Carolina, Florida, and Oklahoma.
CMS extended the demonstration five years effective June 1, 2024, carrying it into 2029.
In FY 2024, CMS received 1,791,226 pre-claim review requests and affirmed 97% of them.
1,898,522 claims were reviewed; 1,832,426 were paid and 66,096 were denied — a 3.5% denial rate.
Only 4,695 denials were appealed — roughly 7% of all denials.
51.6% of appealed claims were overturned at Level 1, the most common reason being documentation submitted late rather than a genuine coverage problem.
Prepayment and postpayment reviews approved only 84.4% (41,524 of 49,168) — well below the pre-claim affirmation rate.
MAC decisions averaged 4.7 days, with a 97.7% MAC accuracy rate.
Agencies reaching a 90% affirmation rate on a minimum of 10 requests can choose relief from most reviews.
Choice 3 (Minimal Review with 25% Payment Reduction) was eliminated in the 2024 extension.

What the RCD Is

The Review Choice Demonstration for Home Health Services lets agencies in demonstration states choose how they prove compliance with Medicare home health policy. CMS runs it under Section 402(a)(1)(j) authority to develop improved methods for investigating fraud in federal health programs. It does not change the home health benefit, and it does not change any medical necessity or documentation requirement — it moves the same documentation earlier in the process.

The two remaining choices

Choice	How it works	Cash-flow effect
Pre-claim review	Submit documentation for provisional affirmation before the final claim; services may begin first	Delay before billing, high certainty of payment
Postpayment review	Bill normally; CMS reviews after payment	Fast cash, recoupment risk later

Agencies that do not select default to postpayment review. As part of the June 2024 extension, CMS removed the third option — minimal review with a 25% payment reduction — and required affected providers to move to one of the two above.

Where it applies and since when

State	Demonstration start	Source
Illinois	June 2019	CMS FY 2024 program statistics
Ohio	September 2019	CMS FY 2024 program statistics
Texas	March 2020	CMS FY 2024 program statistics
Florida	September 2021	CMS FY 2024 program statistics
North Carolina	September 2021	CMS FY 2024 program statistics
Oklahoma	December 2023	CMS FY 2024 program statistics

CMS has stated it can expand the demonstration to additional states within the Jurisdiction M MAC footprint where claims analysis shows elevated utilization — which is exactly how Oklahoma was added after CMS found higher allowed expenditures and utilization there than in the remaining JM states.

The FY 2024 Numbers

All figures below come from CMS's Prior Authorization and Pre-Claim Review Program Stats for Fiscal Year 2024, published September 16, 2025, covering October 1, 2023 through September 30, 2024.

Pre-claim review

Metric	Value	Source
Total requests received	1,791,226	CMS FY 2024 program statistics
Total requests completed	1,849,354	CMS FY 2024 program statistics
Total requests affirmed	1,790,902	CMS FY 2024 program statistics
Percent affirmed	97%	CMS FY 2024 program statistics
MAC review timeliness	4.7 days average	CMS FY 2024 program statistics
MAC accuracy rate	97.7%	CMS FY 2024 program statistics

A 97% affirmation rate is the headline most trade coverage leads with, and it is genuinely good news: agencies that submit documentation before billing almost always get affirmed, and they get an answer in under five days.

Claims, denials, and appeals

Metric	Value	Source
Claims reviewed	1,898,522	CMS FY 2024 program statistics
Claims paid	1,832,426	CMS FY 2024 program statistics
Claims denied	66,096	CMS FY 2024 program statistics
Denial rate	3.5%	Calculated from CMS figures
Claims appealed	4,695	CMS FY 2024 program statistics
Share of denials appealed	~7.1%	Calculated from CMS figures
Overturned at Level 1 appeal	51.6%	CMS FY 2024 program statistics

Prepayment and postpayment review

Metric	Value	Source
Completed claim reviews	49,168	CMS FY 2024 program statistics
Approvals	41,524	CMS FY 2024 program statistics
Percent approved	84.4%	CMS FY 2024 program statistics

The gap between 97% and 84.4% is the single most useful comparison in the whole dataset. The same agencies, the same patients, the same documentation requirements — but a 12.6-point swing in outcome depending on whether the record was assembled before billing or reconstructed afterward.

The Appeal Gap Is Real Money

Here is the arithmetic most agencies never run. In FY 2024, 66,096 RCD claims were denied and roughly 4,695 were appealed. Of those appealed, 51.6% were overturned — about 2,423 claims restored.

That leaves roughly 61,400 denied claims that were never appealed at all. If those denials resembled the appealed ones, roughly half of them were also winnable.

Scenario	Denied claims	Appealed	Overturned
What happened (FY 2024)	66,096	4,695	~2,423
If every denial had been appealed at the same success rate	66,096	66,096	~34,100
Difference	—	—	~31,700 claims

Illustrative calculation applying the CMS-reported 51.6% Level 1 overturn rate to all FY 2024 RCD denials. Actual outcomes would vary; unappealed denials are not necessarily comparable to appealed ones.

Value those roughly 31,700 claims at the MedPAC-reported average Medicare payment of about $2,024 per full 30-day period and you land near $64 million in industry-wide revenue that was denied, probably winnable, and never contested. Scale that to a single agency: if you had 40 RCD denials last year and appealed none of them, the CMS data says roughly 20 were likely recoverable.

Agencies do not skip appeals because they are lazy. They skip them because nobody owns the denial queue, the dollar amount per claim feels small, and the documentation needed to win is scattered across the clinical record. All three are fixable, and all three are accounting-process problems rather than clinical ones.

Tracking denials, appeal status, and recovery by reason code alongside your revenue ledger is the fix, and it is ordinary bookkeeping structure rather than a special project. The same reconciliation feeds your year-end close and your Medicare cost report filing.

What to Do With This

Count your denials from the last 12 months and count your appeals. If the second number is near zero, you have found money.
Sort denials by reason code. CMS says late documentation drives most overturns — that category is where your win rate will be highest.
Appeal the documentation-timing denials first. They are the cheapest to win and require no new clinical judgment.
Compare your own pre-claim affirmation rate to the 97% national figure. Materially below it means a documentation-assembly problem, not a coverage problem.
Check whether you are above the 90% threshold on a minimum of 10 requests. If you are, you can choose relief from most reviews — and many eligible agencies never make the selection.
If you defaulted into postpayment review, reconsider. The 84.4% approval rate versus 97% pre-claim affirmation is the cost of that default, paid in recoupments.
Model the cash-flow trade honestly. Pre-claim review delays billing by days; postpayment review risks clawbacks months later against current receipts. For most agencies the certainty is worth more than the days.
If you operate outside the six states, watch Jurisdiction M. CMS added Oklahoma on utilization data alone and retains authority to add more.

The Bottom Line

The RCD data is one of the few places CMS publishes its own scorecard, and the scorecard says agencies are winning the reviews they contest and losing the ones they ignore. A 97% affirmation rate means the documentation standard is achievable. A 51.6% overturn rate means half the denials were wrong. And a 7% appeal rate means the industry is leaving most of that on the table. The demonstration runs into 2029, so this is a durable process to build, not a one-year scramble. If you want your denial and appeal history analyzed against these benchmarks, schedule a free consultation.