A structured, 100% pre-claim review process helped the client move from an affirmation rate below 85% to a consistent 98%, while improving chart packaging, clinician feedback, office efficiency and confidence in RCD submissions.
98%
Consistent affirmation rate
400
Claims cleared monthly
100%
Charts reviewed
6 MO
Progress toward exiting 100% PCR
OVERVIEW
A review process built for consistency
For home health providers participating in the Review Choice Demonstration, documentation quality can directly influence whether a claim receives an affirmed Unique Tracking Number (UTN). For this client, early PCR cycles exposed recurring documentation gaps and inconsistent interpretation of payer requirements.
Red Road Health Solutions was brought in to work directly within the client’s EMR and create a more dependable review process. The approach combined complete chart auditing, payer-specific review, corrective feedback and end-to-end packaging and submission support.
THE SHIFT
Instead of identifying documentation problems after submission, Red Road helped the client identify and resolve deficiencies before the chart reached the payer.
The case study in one view
BEFORE
Affirmation rate below 85%
Recurring F2F, order and SMART goal deficiencies
Internal staff burden around chart packaging
Risk of write-offs
RED ROAD INTERVENTION
100% chart review + payer-specific checks
Deficiency identification + feedback loop
Red Road packages and submits charts
Pre-submission quality control
BEFORE
Consistent 98% affirmation rate
More consistent documentation
Improved office efficiency
Write-offs avoided
Before Red Road
<85%
Initial affirmation percentage across early PCR cycles
With Red Road
98%
Consistent affirmation rate, sustained month over month
OVERVIEW
The problem was not volume. It was consistency.
The client had experienced issues during its initial PCR cycles, with an affirmation percentage of less than 85%. The recurring gaps were concentrated in key areas of the clinical documentation package:
01
Face-to-face documentation that did not consistently satisfy payer expectations.
02
Orders with deficiencies or missing elements.
03
SMART goals that were not consistently documented to the expected standard.
04
Variations in how Palmetto requirements were interpreted and applied.
05
Operational time spent reviewing, packaging and preparing charts for submission.
OVERVIEW
The problem was not volume. It was consistency.
The client had experienced issues during its initial PCR cycles, with an affirmation percentage of less than 85%. The recurring gaps were concentrated in key areas of the clinical documentation package:
01
Face-to-face documentation that did not consistently satisfy payer expectations.
02
Orders with deficiencies or missing elements.
03
SMART goals that were not consistently documented to the expected standard.
04
Variations in how Palmetto requirements were interpreted and applied.
05
Operational time spent reviewing, packaging and preparing charts for submission.
WHY THIS MATTERED
Each documentation gap created additional review risk. More importantly, the client needed a repeatable process that could identify patterns, give clinicians specific feedback and prevent the same issues from recurring.
THE SOLUTION
A 100% pre-claim quality-control layer
For home health providers participating in the Review Choice Demonstration, documentation quality can directly influence whether a claim receives an affirmed Unique Tracking Number (UTN). For this client, early PCR cycles exposed recurring documentation gaps and inconsistent interpretation of payer requirements.
How the process worked >
01
Review
Red Road reviews 100% of charts for required documentation and potential deficiencies.
02
Validate
The team checks face-to-face documentation, orders, SMART goals and other relevant elements against payer-specific requirements.
03
Identify
Deficiencies are flagged before submission, reducing the likelihood that avoidable gaps reach the payer.
04
Package
Red Road prepares and packages the chart for PCR submission, reducing administrative workload for the client.
05
Submit
Completed packages are submitted under the RCD process with the required information in place.
06
Learn
Review findings are translated into specific clinician feedback, creating a continuous documentation improvement loop.
THE DIFFERENCE
Red Road did not treat PCR as a one-time submission task. The review process became a feedback system that continuously improved the quality of the documentation going into the next submission.
RESULTS
Measurable improvement, from review to revenue protection
With Red Road managing the pre-claim review, chart packaging and submission process, the client achieved a stronger and more consistent PCR performance while reducing operational friction.
What changed >
Higher affirmation performance
The client moved from an initial affirmation percentage below 85% to a consistent 98% affirmation rate.
More claims cleared
Red Road supports the clearance of approximately 400 claims each month with an affirmed UTN.
Better documentation quality
Review findings gave the client specific, actionable feedback to share with clinicians, supporting more consistent documentation.
Package
Red Road prepares and packages the chart for PCR submission, reducing administrative workload for the client.
Submit
Completed packages are submitted under the RCD process with the required information in place.
Learn
Review findings are translated into specific clinician feedback, creating a continuous documentation improvement loop.
IMPACT SUMMARY
Revenue cycle
Fewer preventable documentation-related risks and write-offs
Clinical documentation
More consistent documentation through targeted feedback
Operations
Less internal effort for chart packaging and submission
PCR performance
Affirmation rate improved from <85% to a consistent 98%
Scalability
A repeatable review model supporting ~400 cleared claims monthly
THE TAKEAWAY
Better reviews start before the claim is submitted.
The client’s RCD challenge was ultimately a process challenge: documentation requirements needed to be interpreted consistently, checked systematically and translated into actionable clinical feedback.
By placing a 100% pre-claim review layer inside the client’s workflow, Red Road helped turn PCR from a reactive administrative step into a proactive quality-control process. The result was a 98% consistent affirmation rate, stronger documentation practices, improved office efficiency and a clearer path toward exiting 100% PCR.
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