Home Health & Hospice Week

Qualifying for a deadline exception can save HHAs big.

Although it’s been more than half a year since Medicare started imposing late Request for Anticipated Payment financial penalties, they can still take a toll on home health agencies.

Reminder: Since Jan. 1, HHAs have had five days from the start of care to submit a no-pay RAP. If they don’t, they incur a 1/30 financial penalty for every day they are late with a billing period’s RAP.

The late RAP issue is “certainly a little better than before” now that agencies have experience, allows reimbursement expert M. Aaron Little with BKD in Springfield, Missouri. But “it’s still a problem,” Little emphasizes.

“Where it’s really been problematic has been situations where payment periods overlap with a previous period started by another agency, or even their own agency,” Little tells AAPC. “That information is available on the [Common Working File], but it’s still not always caught prior to billing,” he explains. That results in “a real possibility that a no-pay RAP might be late and the penalty not qualifying for an exception.”

Only four narrow circumstances qualify agencies for exceptions — (1) Fires, floods, earthquakes, or other unusual events that inflict extensive damage to the HHA’s ability to operate; (2) An event that produces a data filing problem due to a CMS or MAC systems issue that is beyond the control of the HHA; (3) A newly Medicare-certified HHA that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from its MAC; and (4) “Other circumstances determined by the MAC or CMS to be beyond the control of the HHA,” according to CMS and the MACs.

Even when agencies do qualify for one of those exception categories, they may be messing up their chance at relief by bungling the exceptions filing process.

How it works: “Home health providers may request an exception to the late RAP penalty by reporting KX modifier on the final claim with the Health Insurance Prospective Payment System (HIPPS) code on the revenue code 0023 line,” HHH Medicare Administrative Contractor CGS instructs on its website. “In addition, you must include information in the ‘REMARKS’ field indicating the reason the RAP was submitted untimely.”

Problem #1: An agency submits a RAP for the initial 30-day billing period, but forgets the RAP for the second 30-day billing period.

Solution #1: “Under PDGM, a RAP is required for each 30-day period claim, unless the claim is a LUPA,” MAC Palmetto GBA advises agencies in a frequently asked question set for late-RAP penalties. Submit a RAP for every billing period.

Problem #2: Agencies include the KX modifier but neglect to include the relevant details in the “REMARKS” section, CGS reports. Or the comments describing the circumstances may be too vague for a determination.

Solution #2: In such cases, “CGS will issue a non-medical review additional development request (Non-MR ADR) with reason code 7RMRK,” it explains. “Submit clear information that demonstrates one of the four circumstances. For example, if the RAP was late due to a claims processing issue, document which issue caused the delay,” the MAC advises.

Problem #3: Once an agency requests an exception and receives a decision, then it can file an appeal if it chooses. “CGS has seen an increase of redeterminations, (1st level of appeal) being submitting without first requesting an exception for an untimely request for anticipated payment (RAP),” the MAC reports. “A redetermination is not acceptable if an exception has not yet been submitted.”

Solution #3: “If the final claim was submitted without the KX modifier, and you wish to request an exception, you may submit an adjustment (type of bill XX7) or a reopening request (type of bill (XXQ) and add the KX modifier and information in the REMARKS field,” CGS instructs. Once you receive an exception decision, then you may appeal it.

Problem #4: An agency submits the no-pay RAP within five business days of the “From” date. The system applies the late penalty.