Home Health & Hospice Week

Will you stick out like a sore thumb?

You’d better rein in any sloppy RAP practices you’ve slid into, or you could get caught up in Medicare’s crackdown on Request for Anticipated Payment abuse.

Why? A new Medicare transmittal issues “instructions to the Medicare Administrative Contractors … on the responsibilities to monitor home health agencies misuse of RAPs,” it says. Change Request 10789 details “steps regarding education, corrective action plans, as well as suppression of RAPs.”

MACs should “identify instances where a Home Health Agency’s (HHA) use of RAPs indicates potential fraud, waste or abuse,” the CR says. While the Centers for Medicare & Medicaid Services acknowledges that “such instances should be rare,” it notes that “corrective action includes, but is not limited to, education, warnings, Corrective Action Plans (CAPs), RAP suppression, and referrals to the Unified Program Integrity Contractor (UPIC).”

RAP fraud and abuse isn’t exactly a new target area. “The MACs have been monitoring misuse of RAPs for several years and have implemented CAPs and RAP suppression on select providers,” notes the National Association for Home Care & Hospice. “However, the MACs have been enforcing appropriate RAP submission based on their individual policies.”

Here are shady RAP scenarios MACs will target, according to the CR:

• more RAPs than final claims filed;
• autocanceled RAPs;
• variation in the number of RAPs submitted “on key markers” such as weekly, monthly, etc.;
• beneficiary anomalies such as benes with two or more admit dates during an episode;
• “the intensity of relationships between HHAs where at least one is already on RAP suppression;” and
• “Other behavior indicative of misuse.”

What’s next: When the MAC finds aberrant RAP submission patterns, it will start with education and monitoring, then may move on to corrective action — including RAP suppression.

The new CR puts more emphasis on the problem of RAP fraud and abuse, observers note. And it “provides standard instructions for enforcing appropriate RAP submissions,” NAHC points out.

Up to your MAC: But the transmittal “still leaves discretion for the MACs in terms of the metrics used to identify fraud, waste, and abuse,” the trade group says in its member newsletter.

Note: The transmittal is at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R817PI.pdf.