Home Health & Hospice Week

Medicare system snafus compound RAP confusion.

Medicare has been supplying just what home health agencies don’t need as they try to get new no-pay RAPs out the door on time and with accuracy — a host of system glitches confusing the issue.

Here are issues plaguing HHA RAPs and claims:

• Reason code W7216: RAPs are returning to provider (RTP’ing) incorrectly with home health reason code W7216, for an invalid line-item date, multiple MACs report. “Medicare Administrative Contractors (MACs) shall suspend requests for anticipated payments (RAPs) receiving reason code W7216 so that they can bypass the edit and allow the RAP to process,” HHH MAC Palmetto GBA says on its website. Back in February, HHH MAC CGS said it was suspending such RAPs in “status/location S MWRAP” and overriding the edit to allow the RAP to continue processing when appropriate. This month, Palmetto GBA said in an update that “MACs shall continue to apply this bypass until the edit can be corrected in the April 2021 release.”
• Value code QF: “The penalties for late requests for anticipated payments (RAPs) are correctly applying on the claim for the late RAP,” says CGS on its claims processing issues log. “However, the claim’s penalty amount (shown with value code QF) is not being deducted from the final reimbursement of the claim, which is causing an out of balance on the remittance advice (RA). This out of balance is showing in the ‘Adjustment to Balance’ field on the RA Summary page.”
• HIPPS Code: “On some claims, the submitted HIPPS code is not being replaced by the system-calculated code, when applicable,” Palmetto GBA notes on its website. Reminder: HIPPS codes on the RAP and final claim must match, and the claims system is supposed to pay the final claim based on its own calculation instead of the submitted HIPPS code.

This problem is not yet resolved, laments M. Aaron Little with BKD in Springfield, Missouri. “For some reason the claims are actually paying — incorrectly — the dummy HIPPS code amount rather than the claim edits properly recoding and paying the correct HIPPS code amounts,” Little tells AAPC.

• Early RAPs: “The Home Health Pricer program is incorrectly applying a penalty to RAPs received more than five days earlier than the ‘From’ date of the RAP,” HHH MAC National Government Services reports on its claims production alert webpage. “The associated claims cannot be readily identified for MAC suspension.”

The good news is a system fix for this problem was implemented on March 1. MACs are varying how they handle the incorrect penalties, though. “Within 20 business days of the fix, Palmetto GBA will adjust claims that had the late RAP penalty applied incorrectly for RAPs received more than 5 days early,” it says. Neither CGS nor NGS give a timeline for their related adjustments.

Billing experts also report some errors they’ve seen that haven’t made it onto the MAC websites yet. For example, a “new thing that started this month relates to RAPs from 2020 payment periods that, for one reason or another, aren’t yet paid,” Little says. “Instead of the RAPs paying the 20 percent estimated claim payment, they’re instead paying weird amounts that make no sense, like $79.” Little expects the final claims for those RAPs to pay the appropriate balance, but it delays the cash and adds confusion.

CMS has already resolved a few no-pay RAP-related claims glitches, including one where Low Utilization Payment Adjustment claims that paid nothing due to late-filed RAPs were “causing out of balance problems on the remittance advice,” according to Palmetto.

In another problem HHAs experienced, Medicare informed agencies that when they bill a subsequent billing period at the same time as the first billing period and use the first day of the subsequent period as the line 0023 date, then they must also use that as the 0023 date on the final claim. “The service dates on 0023 of the RAP and claim must match,” Palmetto instructs.