Home Health & Hospice Week

NOA delay to 2022 isn’t the solution providers hoped for.

If there was an idea commenters on the 2020 home health proposed rule hated as much as RAP elimination, it was implementation of a Notice of Admission requirement. But CMS has finalized that one too, with one burdensome change.

Home health agencies must start submitting NOAs in January 2022 instead of the proposed January 2021, the Centers for Medicare & Medicaid Services says in the 2020 final rule issued Oct. 31. Agencies that fail to file the NOA within five days of the start of care will receive a 1/30 penalty for every day the NOA is late.

While the one-year delay might normally be welcomed with relief, the replacement CMS implements instead is just as bad, if not worse.

In January 2021, HHAs must submit “no-pay RAPs,” CMS says in the final rule scheduled for publication in the Nov. 8 Federal Register. Again, that might be burdensome without the accompanying payment, but not a big deal. Instead, a major problematic requirement accompanies the no-pay RAP provision. Like with NOAs, HHAs must submit the no-pay RAP within five days of the start of care or face a 1/30 payment penalty for every day.

How it works: For both NOAs and no-pay RAPs, the penalty starts accruing on the first day of the billing period. So, if the agency turns in the NOA or no-pay RAP on day 6 — one day late — it will lose 6/30 of its PDGM payment for the billing period — 20 percent, CMS explains in the rule.

CMS specifies in the rule what it will require for the NOA when it starts in 2022:

1) a written or verbal order from the physician (containing the services required for the initial visit) signed and dated by the physician, and if verbal, signed and dated by the registered nurse or qualified therapist … responsible for furnishing or supervising the ordered service in the plan of care signed by the physician; and

2) for the HHA to conduct the initial start of care visit.

In the final rule, CMS shoots down the barrage of criticisms commenters on the proposed rule offered.

For example: CMS won’t extend the time frame to 10 to 14 days, or even just seven days, because “the 5 calendar day timely-filing requirement would ensure that the Medicare claims processing system is alerted as soon as possible to mitigate any potential claims denials of other providers for services that should be covered under the home health benefit,” according to the rule. “Furthermore, the longer the NOA submission timeframe, the higher the uncertainty for providers to determine home health periods of care for a beneficiary.”

CMS also dismisses the idea of implementing the NOA without a financial penalty. “Having a penalty or a reduction in the payment amount for NOAs submitted after the 5 calendar day timely filing requirement is appropriate to aid in expediting the submission of the NOA, triggering consolidated billing edits as soon as possible and reducing claim rejections for other providers who are providing care for a beneficiary who is already under a home health episode,” the agency maintains.

CMS also repeatedly points to hospice Notices of Election as a guidepost for the NOAs. “We have found the reduction in payment amount for failure to submit an NOE to be an effective tool in ensuring timely NOE submission and believe it would be appropriate to apply a similar policy to home health,” the rule notes.

But hospices have plenty of horror stories about NOE implementation, including lingering system failures, and reimbursement losses due to the requirement, industry veterans say.

The NOA adds up to a new adminis­trative requirement for HHAs with no benefit. “Full compliance just establishes the ability to get the claim paid, but any delay from a myriad of reasons will result in further decrease in payment,” says Joe Osentoski with Quality in Real-Time in Sterling Heights, Michigan.