Home Health & Hospice Week

LUPAs thresholds to vary under PDGM.

The home care industry may hate the idea, but CMS is pushing ahead with its proposal to phase out Requests for Anticipated Payment under the newly proposed Patient-Driven Groupings Model.

When the Centers for Medicare & Medicaid Services issued basically the same payment reform model last year as the Home Health Groupings Model, it “solicited comments on the possibility of phasing out the split percentage payment approach in the future,” CMS notes in its 2019 Home Health Prospective Payment System proposed rule that contains the re-proposed revamp. “Commenters did not provide suggestions for a phase-out approach.”

Despite the fact that HHGM “commenters generally expressed support for continuing the split percentage payment approach in the future under the proposed alternative case-mix model,” according to the rule, CMS continues to advance the idea of eliminating RAPs. “As a result of the reduced timeframe for the unit of payment … a split percentage approach to payment may not be needed for HHAs to maintain adequate cash flow,” CMS argues.

The rule cites some stats to support the agency’s position. “Currently, about 5 percent of requests for anticipated payment are not submitted until the end of a 60-day episode of care and the median length of days for RAP submission is 12 days from the start of the 60-day episode,” CMS says. “As such, we are reevaluating the necessity of RAPs for existing and newly-certified HHAs versus the risks they pose to the Medicare program.”

CMS also cites a few extreme fraud cases to support its assertion that “RAP payments can result in program integrity vulnerabilities” (see below).

Instead, CMS’s examples show how incompetent the agency and its contractors were in using their existing tools to detect and stop the fraud, maintains attorney Robert Markette Jr. with Hall Render in Indianapolis. When a large portion of an agency’s RAPs fail to have corresponding end of episode claims filed, Medicare can suspend the offending agency’s payments, Markette points out.

If CMS eliminates RAPs, it will be punishing law-abiding providers instead of targeting criminal enterprises like those it cited in the rule, Markette tells Eli.

Plan on it: Given how persistent CMS is with the idea of scrapping RAPs, HHAs can be pretty certain that “RAPs are going away” in the next few years, Markette predicts. Smart agencies will plan for the change and prepare now, he advises.

In the rule, while CMS says it won’t suggest cutting RAPs for existing HHAs now, it is “soliciting comments on reducing the percentage of the upfront payment incrementally over a period of time.”

Newly enrolling HHAs are not so fortunate. CMS proposes “not to allow newly-enrolled HHAs, that is HHAs certified for participation in Medicare effective on or after January 1, 2019, to receive RAP payments beginning in CY 2020.” It also proposes requiring them to submit a “no-pay RAP” to establish a home health benefit period in the system.

Plus: “If in the future the split percentage approach was eliminated, we are also soliciting comments on the need for HHAs to submit a [notice of admission] within 5 days of the start of care to assure being established as the primary HHA for the beneficiary during that timeframe and so that the claims processing system is alerted that a beneficiary is under a HH period of care to enforce the consolidating billing edits as required by law.”

Do this: Agencies should use the opportunity to comment on the rule to try to change the outcome, Markette and other experts urge.

The changes in the 2019 proposed rule “are significant, impacting not only payments but potentially timing of payments,” emphasizes The Health Group in Morgantown, West Virginia. “Home health agencies need to provide comment on the proposed rule,” the consulting firm counsels.

And this: “With the finalization of the proposed rule, assess the potential reimbursement and cash flow impacts that will result,” The Health Group urges in its electronic newsletter. Other billing-related provisions include:

• 30-day clarifications. CMS is moving forward with transitioning PPS to a 30-day billing period rather than the current 60-day episode (see story, p. 186). But care planning requirements will stay on a 60-day schedule, CMS spells out in the rule scheduled for publication in the July 12 Federal Register.

“The comprehensive assessment would still be completed within 5 days of the start of care date and completed no less frequently than during the last 5 days of every 60 days beginning with the start of care date, as currently required by §484.55, Condition of participation: Comprehensive assessment of patients,” the rule clarifies. “In addition, the plan of care would still be reviewed and revised by the HHA and the physician responsible for the home health plan of care no less frequently than once every 60 days, beginning with the start of care date, as currently required by §484.60(c), Condition of participation: Care planning, coordination of services, and quality of care.”

• LUPAs. The calculation methodology for Low-Utilization Payment Adjustments will stay the same, with Medicare using Fixed-Dollar Loss and Loss-Sharing Ratio figures to determine who gets additional payments. However, PDGM would revise LUPA thresholds.

Instead of the current five-visit threshold for all case mix categories, PDGM would set the threshold at two to six visits depending on the category, the rule explains. Currently LUPAs account for about 8 percent of episodes, while CMS forecasts they will make up 7.1 percent of 30-day episodes under PDGM.

In response to criticism in last year’s HHGM rulemaking, CMS says “we do not believe that the case-mix-specific LUPA thresholds would result in additional administrative burden as LUPA visits are billed the same as non-LUPA periods.”

Resource: CMS lists the individual case mix categories’ LUPA thresholds in Table 47 of the rule. Those categories with thresholds higher than the current level (i.e., six visits) include six MS Rehab Early/Institutional categories and three Neuro - Medium Early/Institutional categories.

• PEPs, outliers. The procedures for both Partial Episode Payment adjustments and outliers would remain the same, CMS says in the rule.