Home Health & Hospice Week

Watch out for NOE-like disaster, expert warns.

One payment reform change Medicare is considering could substantially complicate your billing process even as it delays your reimbursement.

In Medicare’s 2019 Home Health Prospective Payment System proposed rule published in the July 12 Federal Register, the Centers for Medicare & Medicaid Services suggests eliminating Requests for Anticipated Payment for new providers starting in 2020, and signals it wants to eliminate RAPs for existing providers eventually too (see Eli’s HCW, Vol. XXVII, No. 24-25).

Problem #1: Banning RAPs for new providers but allowing them for existing providers “would create an unnecessary administrative burden,” points out reimbursement expert M. Aaron Little with BKD in Springfield, Missouri. CMS and the HHH Medicare Administrative Contractors “would have to build logic into the FISS/DDE system to allow some providers the ability to bill and be paid for RAPs and others to bill but not be paid; this would be difficult for software vendors to carry out,” Little judges.

While CMS wants to eliminate new agencies’ RAP payments, it also proposes new HHAs “would still be required to submit a ‘no pay’ RAP at the beginning of care in order to establish the home health episode, as well as every 30-days thereafter,” the rule notes. Requiring no-pay RAPs would cut down on consolidated billing denials and multiple HHAs unwittingly serving one patient.

Problem #2: “There’s already a process and infrastructure built by CMS/MACs/software vendors to bill RAPs,” bristles Little. “If RAPs are so important to facilitate the Medicare home health program, then why not leave that process alone until PDGM is fully implemented and working well and then consider phasing out the payment of RAPs?” he demands.

In last year’s HH PPS rulemaking process, HHAs spoke out vociferously against CMS’s suggestion to eliminate RAPs. Despite that, “we are again soliciting comments on ways to phase-out the split percentage payment approach in the future given that CMS is required to implement a 30-day unit of payment beginning on January 1, 2020,” the rule says. “Specifically, we are soliciting comments on reducing the percentage of the upfront payment incrementally over a period of time.”

Problem #3: CMS cites some egregious cases of RAP fraud and abuse when suggesting RAP elimination (see Eli’s HCW, Vol. XXVII, No. 24-25). Cutting RAPs just punishes compliant providers because CMS and the MACs are too incompetent to stop brazen and obvious fraud schemes, argues attorney Robert Markette Jr. with Hall Render in Indianapolis.

“It’s unbelievable to me that CMS contractors allowed this to occur,” Little says of the cases that resulted in Medicare paying out about $43 million for fraudulent RAPs. “Why is there not better accountability on the MACs and program integrity contractors to prevent this type of thing from occurring?” Little asks.

If and when CMS eliminates RAPs altogether as it would like, “we are also soliciting comments on the need for HHAs to submit a NOA [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,” the rule says.

Problem #4: This would be similar to hospices’ Notice of Election requirement, Little points out. “I’ve been waiting for CMS to take the hospice NOE billing requirements and try to apply them to home health,” Little tells Eli. “This just makes me irate.”

Why? “There is already a process that works just fine,” he exclaims. “It’s called RAPs.” There’s no need for “some new feature called an ‘NOA.’”

Plus, applying the five-day NOE requirement has been very difficult for hospices to manage. “Home health would be even harder,” Little maintains. “The significant piece that hospice doesn’t have that home health does is the OASIS, which takes time to complete.”

CMS itself notes in the rule that “the median length of days for RAP submission is 12 days from the start of the 60-day episode.” The fact that CMS proposes a five-day requirement when the current median submission time is 12 days is “problematic,” Little stresses.

“The rationale that CMS gives doesn’t justify the action they want to take,” Markette judges.

Do this: Comment on the RAP problems and CMS’s other proposals by Aug. 31.

Note: The rule, including commenting instructions, is at www.gpo.gov/fdsys/pkg/FR-2018-07-12/pdf/2018-14443.pdf.