Home Health & Hospice Week

Bad news: Outlier, LUPA payments are affected.

A few no-pay RAP details revealed in the 2021 final rule on home health payment drive home just how important it is to get the new process right.

In the rule published in the Nov. 4 Federal Register, the Centers for Medicare & Medicaid Services clarifies that penalties for no-pay RAPs:

• apply to outliers. “The one-thirtieth reduction would be to the 30-day period adjusted payment amount, including any outlier payment, that the HHA otherwise would have received absent any reduction,” CMS spells out.
• apply to LUPAs. “For LUPA 30-day periods of care in which an HHA fails to submit a timely RAP … no LUPA payments would be made for days that fall within the period of care prior to the submission of the RAP,” CMS explains.
• are the agency’s responsibility. Days disallowed due to late RAPs “would be a provider liability” and “the provider may not bill the beneficiary for these days,” the rule says.

At least CMS makes clear that “the payment reduction could not exceed the total payment of the claim.”

CMS also signals that if an HHA finds out later that a patient has switched from another insurance, such as Medicare Advantage, to original Medicare, that it won’t necessarily get stuck for the payment. Timely filing exceptions include“a CMS or Medicare contractor systems issue that is beyond the control of the home health agency” and “other situations determined by CMS to be beyond the control of the home health agency.” Scenarios like a switch from MA to Medicare that didn’t show up in the system “may fall into one of the established timely filing exceptions,” CMS says in the final rule.

But: HHAs must do the work to prove it. “The home health agency must fully document and furnish any requested documentation to CMS for a determination of exception,” the rule outlines.