Home Health & Hospice Week

HHAs will be hit with double whammy — losing RAP pay and incurring NOA late filing penalties.

If you think getting rid of Request for Anticipated Payments will at least take one item off your billing to-do list, think again. That’s because new Notices of Admission will take their place — but without any accompanying payment. In fact, like hospices’ similar Notices of Election, NOAs may bring a financial penalty if filed late.

“Beginning in CY 2021, we are … proposing that all HHAs submit a one-time submission of a NOA within 5 calendar days of the start of care to establish that the beneficiary is under a Medicare home health period of care,” the Centers for Medi- care & Medicaid Services proposes in the HH PPS proposed rule released July 11. “The NOA would be used to trigger HH consolidated billing edits … and would allow for other providers and the CMS claims processing systems to know that the beneficiary is in a HH period of care.” Newly enrolling HHAs are already performing a similar function by submitting so-called “no-pay” RAPs.

CMS mentioned NOAs in last year’s rule, and received widespread ridicule of the idea from commenters. But it forges ahead with the proposal anyway in the rule published in the July 18 Federal Register.

Double penalty: “Not only is CMS taking away an important mechanism for managing cash flow, but they are in place of it adding a billing transaction that, if not billed timely, actually incurs a cash flow penalty,” says reimbursement expert M. Aaron Little with BKD in Springfield, Missouri. “That’s rough,” he exclaims.

In short, “agencies would now need to complete another document because CMS has changed their payment process” by eliminating RAPs, rues Joe Osentoski, reimbursement recovery & appeals director with Quality in Real Time in Sterling Heights, Michigan.

How it will work: “We are proposing that failure to submit a timely NOA would result in a reduction to the 30-day Medicare payment amount, from the start of care date to the NOA filing date,” CMS says in the rule. That’s roughly how it works for the hospice NOEs, the agency points out.

In other words, “we are proposing that the penalty for not submitting a timely NOA would be a 1/30 reduction off of the full 30-day period payment amount for each day until the date the NOA is submitted,” CMS explains in the rule.

But hospices can tell you they’ve had plenty of trouble with NOEs. “Hospices have adapted — for the most part — to managing the submission of NOEs,” Little says. “But it requires significant diligence and there are still occasions when hospices end up with a NOE-related payment penalty.”

A big problem has been with Medicare’s own system. But CMS maintains in the rule that HHAs shouldn’t encounter those same troubles.

“Implementation of the Electronic Data Interchange (EDI) submission of hospice Notices of Election (NOE) in January 2018 has alleviated the issues,” the rule says. “As such, we are proposing that the home health NOA process would be through an EDI submission, similar to that used for submission of the hospice NOE.” EDI submission should minimize data entry errors. And “because there is already a Medicare claims processing notification of a benefit admission process in place, we believe that this should make the home health NOA process more consistent and timely for HHAs,” CMS says.

Another problem: The NOA burden “may fall disproportionately on smaller agencies with less billing resources,” Osentoski predicts.

Bottom line: The NOA requirement is bound to lead to “cost, confusion, implementation burdens, and more cost,” National Association for Home Care & Hospice President William Dombi tells Eli.

One good thing about the NOA is that it only applies to initial episodes. “We are proposing that the NOA be submitted only at the beginning of the first 30-day period of care (that is, the NOA would not have to be submitted for each subsequent 30-day period of care),” according to the rule.

At least “you only have to submit it once and, as long as the patient stays on home health, the recert will keep the NOA ‘alive,” praises attorney Robert Markette Jr. with Hall Render in Indianapolis. “This will cut down on work in subsequent episodes, as it is one less sheet of paper to prepare.”

However: “If there is any beneficiary discharge from home health services and subsequent readmission, a new NOA would need to be submitted within 5 calendar days of an initial 30-day period of care,” CMS instructs in the rule.

“HHAs will eventually adapt, just like hospices,” Little predicts. “But it will create problems and challenges, just like it has for hospices.”