Home Health & Hospice Week

Here’s the benchmark you should be aiming for.

In Medicare’s latest proposed payment rule for home health agencies, officials have indicated they are looking at getting rid of Requests for Anticipated Payment altogether. But until then, HHAs have an avenue for securing payment nearly up front for a 60-day episode.

However, RAP payments are a privilege, not a right, Medicare indicates in its newest crackdown on home health billing fraud and abuse. To maintain that privilege, HHAs must keep their RAP stats in the acceptable range to keep the upfront cash flowing. But what is “acceptable” when it comes to RAP submissions?

For now, the HHH Medicare Administrative Contractors aren’t saying exactly. MAC CGS did announce that it commenced monitoring of RAP cancellation stats last month (see Eli’s HCW, Vol. XXVII, No. 34). And a spokesperson for MAC Palmetto GBA tells Eli it has been monitoring RAP statistics since as far back as 2013.

A Centers for Medicare & Medicaid Services transmittal instructing the MACs to implement RAP monitoring says only that “potential fraud, waste or abuse” could include “situations where an HHA exhibits a high rate of final claims not being filed.”

In an article on RAP fraud and abuse posted to its website, Palmetto says “a high rate of RAPs canceled versus final claims processed” could trigger RAP suppression or a warning letter. An “excessively high RAP cancellation rate” will lead to RAP suppression. “Instances where the RAP is canceled because the final claim was not submitted should be minimal,” the MAC says.

Palmetto doesn’t get more specific with RAP cancellation rate red flags because “our analysis is not limited to specific defined thresholds,” the Palmetto representative says. “The ratios and percentages indicating likely misuse may vary according to the specific attributes of each home health agency’s billing behaviors.”

Likewise, CGS doesn’t offer any benchmarks for RAP cancellations in its education material either.

25%, 50%, 200% May Be Your Benchmarks

While the MACs may not offer specific stats for HHAs to avoid, experience with Palmetto’s years of RAP monitoring does yield some clues as to what the contractor is looking for.

“For PGBA, what we’ve seen is that warning letters can be issued when the RAP cancellation rate is 50 percent or higher and suppression be applied when the cancellation rate is in the 200 percent range,” offers reimbursement expert Aaron Little with BKD in Springfield, Missouri. The bottom line is an agency “should be concerned of MAC action if rates are 50 percent or higher,” Little advises.

Palmetto is clearer about the benchmark it uses to take HHAs off RAP suppression. After three months of suppression, the MAC will look at agencies’ RAP cancellation rate. “The current threshold for reinstating RAP payments is a RAP cancel rate of less than 25 percent,” Palmetto says on its website.

If agencies don’t make that cutoff, they are in for another three months of suppression, CMS indicates in its transmittal.

HHAs may want to consider a 25 percent-or-under cancel rate as their goal, since this is the metric Palmetto uses to let HHAs off suppression, suggests Joe Osentoski, reimbursement recovery & appeals director for QIRT in Troy, Michigan.

Do this: “Providers are encouraged to monitor their outstanding RAPs to ensure the final claim is submitted timely,” Palmetto says. “This will assist the provider in determining if changes are needed to their processes to avoid a high rate of RAPs that are canceled because the final claims is not submitted on time.”

Bottom line: “The higher the percentage of RAP cancellations, the more at risk the provider is of having their RAPs set to process with zero payment,” Palmetto warns.

Note: Palmetto’s RAP monitoring article is at www.palmettogba.com — click on “Jurisdiction M Home Health and Hospice MAC” in the right column, then choose “Articles” from the “Topics” pull down menu in the top bar, then click on the “Home Health” link and choose the Aug. 24 article in the article list.