Home Health & Hospice Week

Problem: CMS has discovered that the claims system edit that prorates 30-day billing periods for late RAPs is also prorating them for early RAPs, a CMS official explained in the Jan. 26 Home Health Open Door Forum. If a RAP for a second billing period is more than five days early, the payment amount for that period will be prorated based on how many days early it is, the staffer explained.

“Unfortunately, this error can’t be corrected in Medicare systems until March 1,” the CMS source told forum attendees. That means HHAs have two choices:

1. Hold any second-period RAPs until they are no longer early, up until March 1.
2. Go ahead and submit the early RAPs and the claim system automatically will correct your prorated payment after the March 1 fix takes effect.

“It’s up to you” which method you choose, the CMS official told a caller in the question-and-answer session. The payment correction will happen “without you doing anything,” he noted.

On one hand: Waiting on the automatic correction of your payment could be a problem if the March 1 fix doesn’t work, or if the system takes a long time to process the erroneously prorated claims, experts caution. It could also cause some challenges when it comes to reconciling your billing.

On the other hand: If you hold your RAP and then miss the second period’s five-day billing window, you’ll be financially penalized.

With no written guidance yet, the best option may not be entirely clear. But reimbursement expert M. Aaron Little with BKD in Springfield, Missouri, emphasizes the importance of not missing the five-day window. Agencies “should continue to be diligent in getting the RAPs billed within the 5-day period,” Little urges.

It’s not surprising that new payment provisions arrive with some kinks to work out. “No one thought the year would start off without some hiccups in the no-pay RAP billing,” Little tells AAPC.

The CMS staffer acknowledged the lack of written guidance thus far and advised attendees to watch their Medicare Administrative Contractor for a notice

Returned RAPs Not A Lost Cause

The CMS billing staffer also gave HHAs some hope when they have RAPs returned after the five-day penalty window.

How it works: If you submit a RAP and it gets returned to provider (RTP’d), the RAP is given a new receipt date when you resubmit it, the CMS official reviewed. If that new receipt date is past the five-day window, even if the originally submitted RAP is within that window, it will count as late and trigger proration of your episode payment rate. “That’s why you want to work those as promptly as you can,” he advised of returned RAPs.

But sometimes an agency will submit the RAP on time, then get it back days later, after the five-day window. The period then is subject to proration when the agency resubmits, even though it took the MAC days to return the RAP, a caller protested in the Q&A session.

In that case, you may want to request a timely filing exception, the CMS source suggested.

Reminder: The home health payment final rule for 2021 specified that agencies can request timely filing exceptions to RAP requirements — proration. “CMS may waive the consequences of failure to submit a timely-filed RAP if it is determined that a circumstance encountered by a home health agency is exceptional and qualifies for waiver of the consequence,” the agency explained in the rule published in the Nov. 4, 2020 Federal Register.

Two of the valid reasons for an exception include “a CMS or Medicare contractor systems issue that is beyond the control of the home health agency” and “other situations determined by CMS to be beyond the control of the home health agency,” the rule notes.

Do this: If you want to request a timely filing exception, submit the claim with a KX modifier and add remarks to the claim explaining what happened, the CMS source instructed. “If an HHA believes that there is a circumstance that may qualify for an exception, the home health agency must fully document and furnish any requested documentation to CMS for a determination of exception,” the rule elaborated.

Further instructions are in a September update to Change Request 11855. “The HHA should provide sufficient information in the Remarks section of its claim to allow the MAC to research the exception request. If the remarks are not sufficient, the MAC will request documentation from the HHA,” the CR update says.

Providers don’t have forever to take advantage of this exception, though. “HHAs should resubmit corrected RAPs promptly (generally within 2 business days of canceling the original RAP),” CMS instructed in the CR.

Note: CR 11855 is at www.cms.gov/files/document/r10403CP.pdf.