Home Health & Hospice Week

Don’t be surprised when problems come to light.

If you thought it would take a while for Medicare Administrative Contractors to get into the habit of monitoring Requests for Anticipated Payment for fraud and abuse, think again.

Last month, Medicare Change Request 10789 issued “instructions to the Medicare Administrative Contractors … on the responsibilities to monitor home health agencies misuse of RAPs.” In the transmittal, the Centers for Medicare & Medicaid Services detailed “steps regarding education, corrective action plans, as well as suppression of RAPs.”

Now, HHH Medicare Administrative Contractor CGS has given notice that it began the monitoring Sept. 17. As of that date, “as instructed by CMS, CGS will routinely monitor FISS claim data to prevent instances of potential fraud, waste, and abuse,” the MAC says.

CGS notes that “such instances should be rare.” But the MAC will be on the look out for “the number of final claims submitted being less than the number of RAPs submitted generally” and “the number of final claims submitted late resulting in RAPs being auto-canceled,” as well as other problems.

“CGS will monitor FISS claim data for a reasonable period of time,” the MAC says on its website. When monitoring identifies potential misuse, CGS may take steps including education; a Corrective Action Plan (CAP); RAP suppression; and/or referral to the Unified Program Integrity Contractor (UPIC), the MAC warns.

“CGS will notify the HHA of the action taken and the next steps, upon completion of the monitoring period,” according to the MAC.

Watch out: This monitoring “is going to end up highlighting problems in some agencies that may have gone undetected or unresolved,” warns reimbursement expert M. Aaron Little with BKD in Springfield, Missouri. MAC Palmetto GBA “has been doing this type of monitoring for a few years now and we have seen numerous providers end up either on RAP suppression or receiving RAP suppression warning letters,” Little tells Eli.

The good news is that “agencies with sound billing practices should not be affected,” says consultant Joe Osentoski with QIRT in Troy, Michigan.

“If an agency has matching RAP and final bills and bills timely, they should not see any additional issues.”

But agencies going through situations like these may end up with RAP problems, Little cautions:

• disruptions caused by ownership changes or software conversions,
• untrained or unknowledgeable billing and revenue cycle personnel,
• staff turnover, and
• poor physician order management processes.

Red flag: “Even if this recent initiative was not being pushed by CMS,” providers should be closely monitoring their RAP stats, Little says. “Aside from the direct negative impact on cash flow, it typically is indicative of larger process issues that need to be addressed.”

Note: CGS’s article is at www.cgsmedicare.com/hhh/pubs/news/2018/0918/cope9142.html.