Home Health & Hospice Week

RAP-related closures are on the horizon, state trade group warns.

If you aren’t at peak efficiency in getting your Requests for Anticipated Payment out the door, that could seriously harm your bottom line starting in less than two months.

The 2021 home health final payment rule released Oct. 29 gives home health agencies no relief on the RAP front.

Reminder: This year under PDGM, the Centers for Medicare & Medicaid Services reduced RAP payments to 20 percent of the billing period payment, down from 60 (initial) or 50 (subsequent) percent previously. Next year RAP payments will go down to zero, giving rise to “no-pay RAPs” that CMS still will require agencies to file within five days of the start of care. Each day late the RAP is filed will come with a 1/30 period payment penalty. In 2022, no-pay RAPs will switch to Notices of Admission.

If there is a provision HHAs hate more than behavioral adjustment cuts under PDGM, it is the no-pay RAP and its financial penalties.

COVID-19 “has caused extensive disruption to physician offices as well as hospital operations, delaying contact with physician offices for confirmation of orders,” the Visiting Nurse Service of New York's Marki Flannery told CMS in the VNS's comment letter on the 2021 proposed rule. “There is every indication that these disruptions will continue through 2021. This has led to late RAP submissions that are beyond the control of the HHA,” Flannery said.

“Actively adjusting their processes to speed submission times ... will take some time, especially because of the sub­stantial amount of administrative work that has been shifted to the beginning of an episode/payment unit” for both PDGM and the Review Choice Demonstration, the Illinois HomeCare & Hospice Council emphasized to CMS in its comments. “The five-day submission window is arbitrary and the potential penalties coupled with a zero percent RAP and other pandemic-related effects will have very serious consequences to providers including closure of home health agencies,” the state trade group warned.

“Currently the average days to RAP for a home health patient is 12 days,” Lisa Woolery from Massachusetts said in her comment letter. “This considers the OASIS visit, review, and coding of the episode including transmitting the final OASIS and sending the completed POC,” she noted.

“The operational and financial strains faced by HHAs during the PHE have been great as care has shifted to an even greater extent to beneficiaries’ homes,” noted UnityPoint at Home execs Margaret VanOosten and Cathy Simmons in the health system-based agency’s letter. “As a result, it [has] been difficult at best for many HHAs to operationalize the changes to effectuate the 5-day RAP submission time frame,” they told CMS.

“We fear these payment reductions will be significantly more impactful than anticipated,” they warned.

“It is nearly impossible to float the expense to pay staff to treat patients for the entire 30-60 day period without receiving the RAP payment,” one anonymous commenter told CMS. “The reduction in the RAP payment we received this year was really hard on our cash flow, but at least it was something.” The proposal to eliminate upfront RAP payment altogether along with the five-day deadline penalty “just seems cruel and unnecessary,” the provider chastised. “The whole ‘patients over paperwork’ initiative touted by this administration is not being followed through on at all.”

Bottom line: “We love what we do ... we just don’t know why we are constantly targeted with these changes and near impossible regulations to keep up with,” the anonymous commenter said.

What HHAs wanted: “UnityPoint Health implores CMS to delay the implementation of the payment penalty for a late RAP submission in 2021 until the greater of 6 months after the implementation date or three months after the PHE ends,” VanOosten and Simmons said in the agency’s letter. Many other commenters asked for similar delays.

What HHAs got: CMS didn’t grant any relief on the no-pay RAPs and didn’t address the vast majority of commenter concerns on this topic in the rule.

No-Pay RAP Clarifications Help — A Bit

In a Nov. 4 Home Health Open Door Forum, a CMS official did address some RAP changes that should make filing somewhat quicker and easier.

Change No. 1: In 2021, agencies may report the first day of the period of care as the service date on the RAP's 0023 revenue line, a CMS home health billing expert explained in the forum. CMS had outlined that change, which will prevent RAP submission delays, in recent transmittal CR 11855 at www.cms.gov/files/document/r10396cp.pdf (see HCW by AAPC, Vol. XXIX, No. 37).

Change No. 2: If you are waiting for OASIS finalization to generate the HIPPS code, you can go ahead and file the RAP with any HIPPS code to avoid being late for the five-day deadline, the CMS staffer instructed.

But there’s a catch. The final claim you eventually file must use the same HIPPS code, even if it’s an incorrect one, because the HIPPS codes are used to match up RAPs and claims. It’s OK, because the Medicare claims system will correct the HIPPS code during processing, the CMS official said.

The direction to submit RAPs and claims with incorrect HIPPS codes makes some agencies uncomfortable, they say.

Change No. 3: Starting Jan. 1, CMS will relax the edit that matches RAPs and final claims using the date of the first line item, the CMS source told forum attendees. So your final claim can use the actual first visit date, while your RAP may have the first day of the billing period on the 0023 revenue line (see change no. 1).

If you have lingering RAP questions, you can tune into an educational webinar on the topic from HHH Medicare Administrative Contractor Palmetto GBA on Nov. 19. For registration, go to www.palmettogba.com/palmetto/providers.nsf/docscat/Providers~JM Home Health and Hospice~Articles~General and scroll down to the Oct. 29 article, “Request for Anticipated Payments 2021 Webinar.”