Home Health & Hospice Week

Notice of Admission content still in flux.

When RAPs go away, Medicare wants home health agencies to substitute another kind of submission — a Notice of Admission. Home health agencies are opposing that proposed change, except perhaps if it stays incredibly simple.

Background: In its 2018 proposed rule, the Centers for Medicare & Medicaid Services threw out the idea of creating a Notice of Admission that HHAs would have to file within five days of the start of care. Commenters roundly criticized the suggestion and urged CMS to continue with Requests for Anticipated Payment instead. In fact, commenters on the 2018 rule “did not provide suggestions for a phase-out approach, but stated that they did not agree with requiring a NOA given the experience with such a process under the Medicare hospice benefit.”

Nevertheless, CMS moved forward with eliminating RAPs for new agencies, and in this year’s proposed rule says it wants to reduce RAP payments for existing HHAs to 20 percent in 2020 and eliminate RAPs altogether in 2021 (see story, p. 286).

CMS also carries on with the very unpopular NOA idea in this year’s rule. “If in the future the split percentage approach [to RAPs] was eliminated, we are also soliciting comments on the need for HHAs to submit a NOA 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,” says the rule published in the July 12 Federal Register. “There are significant drawbacks to both Medicare and providers of not establishing a NOA process upon elimination of RAPs.”

HHAs once again take aim at this proposed burden. In the 2020 proposed rule, “CMS tacitly acknowledges that the implementation of the requirement of the NOE caused financial hardship to hospice programs, yet it wishes to implement this process for home health,” criticizes Elizabeth Buckley with Trinity Health At Home headquartered in Livonia, Michigan.

“In citing the new 30-day billing period as a reason for this proposal, CMS is attempting to develop an over-reaching solution to a non-existent problem,” Buckley contends in the health system-based chain’s comment letter. CMS can evaluate this potential issue after PDGM is implemented to see if a problem actually exists.

“CMS also fails to recognize that one of its current burden reduction initiatives is seeking ways to eliminate paperwork that has no effect on patient care or that is burdensome to providers,” Buckley adds. “The NOA proposal squarely contradicts this initiative. This is simply creating documentation and work for a staff member with no benefit to the patient.”

The NOA would increase agencies’ paper- work, says Amie Falgout with Divinity Home Health Services in Louisiana. The NOA proposal “is inconsistent with efforts to reduce burden. We are concerned that the NOA will require too much information in too short of a period of time,” Falgout says in her comment letter.

Multiple commenters blast the idea that an NOA would have to include the same information as the current RAP. “Since the NOA does not generate a payment and only serves to update the CWF, it is baffling why CMS would require agencies to have the same requirements for the NOA submission as for the RAP submission,” says Pat West with Pioneer Home Health Care Inc. in Bishop, California. “Agencies will not likely be able to meet the five-day time frames for submission of the NOA if agencies must comply with all the proposed requirements.”

If CMS does move ahead with the NOA, many commenters urged the agency to make the required elements for the NOA as simple as possible. “We ask that the new NOA requirement include only the beneficiary’s name and start of care date, which is sufficient to accomplish the stated intent of the NOA,” says David J. Totaro with chain BAYADA Home Health Care headquartered in Philadelphia.

CMS also should make compliance part of the survey process, rather than attach a financial penalty for failing to submit an NOA on time, multiple commenters recommended.

A step further: CMS can achieve the same objective without requiring an NOA at all. Rather, CMS should consider “adopting a simple mechanism by which HHAs can make a notation in the Common Working File (CWF) or through the Electronic Data Interchange (EDI) to indicate the beneficiary has been admitted under a home health plan of care,” urges physical therapist Jason R. Falvey, in New Haven, Connecticut.

Outpatient Therapists Up In Arms

HHAs probably shouldn’t expect the NOA requirement to go away altogether, though. Many outpatient therapy commenters expressed the great need for the timely mechanism. An NOA “will help save outpatient physical therapy locations the headache of trying to clarify with a patient if they have had home health, let alone been discharged from it,” says Shauna Ballard in her comment letter. “So many of our Medicare patients do not understand that when they are seen at their home that they can’t been seen by us [at the] same time, not to mention they don’t usually know the actual name of the agency the person is from,” Ballard tells CMS.

“Although we go to great lengths to get home health information from our patients, some simply do not understand what we are asking or are confused about discharge dates,” outpatient provider Kristen Drown says in her comment letter. “This information would be extremely helpful to have before the start of care.”

Many outpatient therapy commenters point the finger at HHAs for the problem. “I can’t tell you how many times my claims were denied due to a completely broken Medicare verification system (both phone and online),” Edward Volodarsky in New York says in his comment letter. “That system is not being updated in a timely manner.”

At fault: “The HHAs often update the patient’s info weeks after the patient was admitted and they never update the actual discharge date,” Volodarsky charges. “So most of the time I have to call the agency and beg them to fax me some confirmation of the discharge date. And although they [are] required to do it by law, half of them will just ignore my request, which results in significant delays in patients’ ability to receive a physical therapy treatment.”

A good-sized chunk of the 560 comments CMS received on the rule are from outpatient therapy providers relating the same types of problems.