More claim denials are being overturned in the Review Choice Demonstration model, according to new 2024 data released by CMS.
 
Providers in Florida, Illinois, North Carolina, Ohio, Oklahoma and Texas participate in the RCD model, which primarily involves pre-claim or postpayment review with options for less oversight for agencies that can prove routine compliance.
 
According to the new data, 51.6% of denied claims were overturned in the first level of appeal. That’s up from 35.4% in 2023. CMS notes that the most common reason for appeal overturns was due to the submission of additional documentation not provided in the initial review.
 
Other notes from the report:
  • Affirmed pre-claim requests remained at 97%.
  • Approved prepayment and postpayment reviews dropped slightly, from 85.5% to 84.4%.