Home Health & Hospice Week

HIPPS codes are the sticking point.

The unusual payment hold on RAPs should let up within a few days, but the 20 percent payment level will still be in place for them.

Some providers might have gotten their hopes up when they saw a reissued version of Change Request 11081 issued Dec. 20, 2019. The reissued transmittal contained new contractor instructions for the Patient-Driven Groupings Model, but neglected to change the RAP payment amounts under PDGM in the “general information” section.

The Centers for Medicare & Medicaid Services will correct the 60/50 percent RAP payment language to the 20 percent level required by PDGM, a CMS official said in the Jan. 8 Home Health Open Door Forum. Expect CMS to reissue the corrected CR any day.

CMS and its contractors also explained why they were holding home health Requests for Anticipated Payment when they usually don’t. “This January, home health Requests for Anticipated Payment (RAPs) are affected by implementation of the Home Health Patient-Driven Groupings Model,” HHH Medicare Administrative Contractor Palmetto GBA details in a message to providers. “MACs will hold RAPs with From dates on or after January 1, 2020, and process them once the updates are complete.” The issue was that the HIPPS codes needed to be loaded into the system for both RAPs and final claims, the CMS staffer explained in the forum.

“The quarterly hold is typical and usually doesn’t really create any cash flow hiccups for the average provider,” notes reimbursement expert M. Aaron Little with BKD in Springfield, Missouri.

The PDGM system changes went live Jan. 6 (the first Monday of the quarter), and MACs could theoretically hold RAPs for the length of the 14-day payment floor like other claims. But MACs should start paying claims “in the next few days,” the CMS official expected.

That squares with what appears to be occurring. “We have submitted our first client RAPs with 1/1/20 dates of services and most have a payment amount already populated,” Melinda Gaboury with Provider Healthcare Services in Nashville, Tennessee, tells Eli.

“I’m anxious to see how long it will take to pay the RAP under PDGM, and if they will stick to the 14+ days for the final claim,” adds Lynn Olson with billing company Astrid Medical Services in Corpus Christi, Texas.

Some providers are running into billing issues generated on their end, Olson also reports. Some “clinical systems providers are using” are having a variety of problems “turning the data into a correct claim,” he says.

Some providers also have reported RAPs with valid HIPPS codes rejecting, the CMS staffer said in the forum. Those reported codes are being fixed.

Reminder: For subsequent episodes, HHAs are still bound by the requirement to wait until a first visit is made before submitting the RAP, the CMS source said in response to a caller question. The exception is for 30-day periods that aren’t expected to contain a visit.