Home Health & Hospice Week

Do feds see RAPs as free loans?

A new RAP suppression instruction shows why home health agencies shouldn’t count on the advance payments sticking around too much longer — for anyone.

New: Effective immediately, the Centers for Medicare & Medicaid Services will begin placing all newly enrolling home health agencies “into a provisional period of enhanced oversight,” CMS says in a

MLN Matters article released Feb. 15. The enhanced oversight will apply to “new HHAs in all states and territories.”

The enhanced oversight “provisional period will include a suppression of all Request for Anticipated Payment (RAP) payments for 30 days to 1 year,” CMS continues. “All new HHAs will not receive RAPs as part of their billing process during the period of time they are in the provisional period of enhanced oversight.” (See more details of the process in box, p. 59.)

The announcement took many in the industry by surprise. While CMS announced in the 2019 rulemaking cycle that new agencies enrolling in 2019 won’t receive RAP payments under the coming Patient-Driven Groupings Model reform that takes effect in 2020, those HHAs were expected to be able to receive RAP payments this year.

CMS maintains in the article that “the provisional period of enhanced oversight will help CMS closely monitor provider or supplier types that historically have engaged in high levels of fraud, waste, and abuse.”

National Association for Home Care & Hospice President William Dombi suspects “CMS considers this to be their substitute for the lifting of the moratoria,” he tells Eli. In a Jan. 30 notice on its website, CMS said it was lifting the moratoria on new HHAs in Florida, Illinois, Texas, and Michigan (see Eli’s HCW, Vol. XXVIII, No. 6).

Others suspect the enhanced oversight and suppression are CMS’s shortcut to getting rid of advance payments that it no longer supports. The agency already eliminated RAP payments for new agencies under PDGM, and solicited comments in the 2019 proposed rule on cutting RAP payments altogether.

However, in the MLN Matters article, CMS maintains that “the provisional period of enhanced oversight authority … is unrelated to a recently published Medicare final rule” that implements PDGM.

Industry veterans aren’t quite buying that assertion. “It’s hard to think it’s completely unrelated,” observes reimbursement expert M. Aaron Little with BKD in Springfield, Missouri. “It feels more like a preliminary step, especially considering the ‘concerns’ about RAP payment abuse that CMS stated in the final payment rule,” Little says.

Those concerns included two fraud cases where HHAs billed and were paid for tens of millions of dollars in RAPs without submitting final claims for more than a year.

“I think that this is completely related to the elimination of RAPs,” says attorney Robert Markette Jr. with Hall Render in Indianapolis. “This RAP suppression gives CMS a tool to eliminate RAPs for providers that enroll going forward.”

“We do have concerns that CMS is not a big supporter of the RAP with the move to a 30-day payment unit,” Dombi notes.

CMS seems to “really not like” RAP payments, “but they are necessary, given the large gap between providing care and the payment of the end of episode claim,” Markette contends.

Will RAPs Soon RIP?

You can expect CMS’s lack of RAP support to translate into RAP elimination for all HHAs soon, experts agree. And that’s despite many agencies’ comments during recent rulemaking periods that oppose the change.

“I can see [RAP elimination] coming to all HHAs by 2022,” predicts Tom Boyd with Simione Healthcare Consultants in Rohnert Park, California.

“RAPs are definitely going away and, if I had to wager, sooner than we may have originally anticipated,” Markette agrees. Watch for a proposal to eliminate RAPs altogether in this year’s proposed rule for 2020 payment, expected out this summer.

Entry barriers: Elimination of RAPs for new providers on the accelerated schedule means “the resources needed to enter the Medicare home health industry become ever greater,” notes Washington, D.C.-based healthcare attorney Elizabeth Hogue.

Bright side: Many providers and industry advocates oppose RAP elimination, but Boyd is a supporter of the idea. Statistics show that “HHAs are getting slower to bill the RAPs,” Boyd tells Eli. In the 2019 proposed HH PPS rule, CMS noted that about 5 percent of RAPs are not submitted until the end of a 60-day episode and the median length of days for RAP submission is 12 days from the start of the episode.

“The government and the providers would both save time and money if the RAP would be eliminated,” Boyd maintains. “I believe we got it in the first place,” when CMS launched HH PPS in January 2000, “because CMS wanted a carrot to help sell PPS to the HHAs,” he adds.

However: RAP elimination isn’t quite a done deal, Dombi stresses. “We still see a strong basis for CMS to continue RAPs, so do not write a eulogy yet,” he says.

Note: See the article www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE19005.pdf.