Home Health & Hospice Week

Focus on the 3 items required in the new RAP.

The reimbursement seas are going to get choppy again under the switch to no-pay RAPs at the first of the year. Make sure you aren’t one of the unfortunate home health agencies that won’t survive it with this expert advice.

1. Move no-pay RAPs to the top of your list. This process change is no joke, and could wipe out the entire period's reimbursement for your patient. Home health agencies must make no-pay Requests for Anticipated Payment their number-one priority, stresses Nick Seabrook with BlackTree Healthcare Consulting in King of Prussia, Pennsylvania.

HHAs might think since RAP payments are going away, so will their significance. “The submission of RAPs, despite the lack of payment, remains extremely important for home health agencies,” warns Washington, D.C.-based healthcare attorney Elizabeth Hogue. “If RAPs are not submitted on time, i.e. within five days of admission, reimbursement to agencies will be reduced either through a payment penalty for the episode/ period of care or a reduction in the number of visits that go toward calculating LUPAs.”

Bottom line: “It’s called leaving money on the table,” Hogue emphasizes. “Agencies simply cannot afford to do so.”

2. Revamp your processes. The way you prepare and submit your RAPs today is not going to work come Jan. 1.

Why? The Centers for Medicare & Medicaid Services is eliminating some items that are now required on the RAP so that HHAs can submit them by the stringent five-day deadline.

Do this: Agencies “need to streamline their processes to just focus on getting the simplified items and sending out the RAP, then coming back to finish the other items,” advises Sherri Parson with consulting firm QIRT, which has been acquired by McBee. “It would … be unrealistic to expect to streamline their normal process down to five days,” Parson acknowledges. Instead, agencies should “adjust their practices to include the few items needed and send out the RAPs as soon as possible,” she urges.

“This is quite a change to the workflow and logic of RAPs,” warns reimbursement expert M. Aaron Little with BKD in Springfield, Missouri.

“Agencies need to understand the new RAP requirements and change their processes internally to be able to get those RAPs out within the five-day time frame,” stresses Lynn Labarta, CEO and founder of Imark Billing in Miami.

3. First check this. Before you go down the rapid RAP road for a patient, make sure you need it. “Agencies will need some kind of insurance verification process to know who they need to send RAPs on,” Parson offers.

4. Secure these three items. To successfully submit a no-pay RAP, HHAs need a verbal order from the physician, the date the first visit was made, and the primary diagnosis, Seabrook says. When you’ve got those in hand, your RAP should go out the door.

HHAs no longer have to complete the OASIS or the plan of care before RAP submission, says the National Asso­ciation for Home Care & Hospice in a no-pay RAP fact sheet.

5. Use a dummy HIPPS code. Since agencies no longer must wait to complete the OASIS before submitting the RAP, how will they generate the HIPPS code that goes on it?

The answer is they won’t, Seabrook explains. Instead, to speed RAP submission, HHAs should use a “dummy” or placeholder HIPPS code on the RAP. Then they must place the same HIPPS code on the final end of episode claim, even if they know it isn’t the right one — which may feel a little weird.

Putting an incorrect HIPPS code on the claim may cause agencies some “discomfort,” since “the HIPPS code is what generates the payment amount,” acknowledges Lynn Olson, owner of billing company Astrid Medical Services in Corpus Christi, Texas.

But using a placeholder HIPPS code on both RAP and claim is perfectly OK under the new no-pay RAP rules, confirmed a CMS official in the Nov. 4 Home Health Open Door Forum (see HCW by AAPC, Vol. XXIX, No. 40). The “correct HIPPS code will be determined by [Medicare claims] payment system” at the end, based on the information contained in the OASIS file, the CMS staffer said.

Some providers are using the lowest possible HIPPS code as their dummy code, while others are using a code that is close to a 1.00 case mix category, Seabrook has seen. It doesn’t really matter which placeholder code you use, since it has no impact on the eventual payment at the end of the billing period, he notes.

While using the placeholder code is allowed and even expected, it’s not great, Labarta judges. “Leaving it up to them to calculate our reimbursements is a scary thought,” she tells AAPC. “If we look at the recent PDGM transition, the [Medicare contractors] were calculating our payments incorrectly right from the very start, so I suspect the same may happen again for the no-pay RAP rule,” she says.

6. Coordinate with your vendor. Exactly how you implement much of these RAP process changes may be determined by your software vendor. “Those agencies who are proactively reaching out to their EMR vendors to understand how to process and account for the no-pay RAPs are going to be best positioned for success come Jan. 1,” Little predicts.

7. Keep OASIS, 485s on the fast track. Just because you won’t need the OASIS and plan of care for RAP submission doesn’t mean you don’t need to get them done as soon as possible, experts stress.

You still need to complete the OASIS within five days of the SOC, according to regulations. And you must secure a physician-signed POC to bill the final claim at the end of the 30-day billing period.

Goal: Aim to get your documentation from the physician back within 10 days, Seabrook recommends. If it isn’t timely, you won’t survive.

“My concern is that people will be even more lax in the timelines for a ‘clean’ OASIS,” says Cindy Krafft, physical therapist and consultant with Kornetti & Krafft Health Care Solutions. “As an outsourced coding and OASIS review provider, we are seeing SOC assessments coming in for review that are over two months old,” she relates. “When errors are found, how does the clinician even recall the details of that visit at this point? Are they just accepting corrections without serious review to move the paperwork on? What does that do to accuracy in the long run?”

8. Bill both RAPs simultaneously. CMS makes clear that agencies may submit no-pay RAPs for the first and second billing period of a 60-day certification episode at the same time. “The HHA may submit [second-period] RAPs with the first day of the period of care as the service date on the 0023 line,” CMS says in a transmittal addressing no-pay RAPs, CR 11855, that’s been updated several times, most recently on Oct. 27. In other words, agencies don’t have to wait until they make a visit in that second 30-day period to bill.

HHAs need to “understand how to generate both RAPs for the first and second period at the beginning of the episode,” Labarta stresses. Again, coordination with the software vendor will be necessary for this, she expects.

HHAs should submit “two RAPs together whenever possible,” Parson stresses.

9. Track RAPs, final payments. You won’t get credit for just submitting a no-pay RAP — it must be accepted or Medicare still will consider it late.

In addition to making sure your RAPs process, you should be tracking what HIPPS code Medicare pays versus what you expect, Seabrook advises. That may get trickier when you don’t necessarily have the HIPPS code you expect to be paid for on the final claim.

“This puts a real emphasis on the importance of closely monitoring Medicare payments to make certain they are processing and paying correctly,” Little says.

Tip: You’ll know when Medicare reduces your claim payment for a late RAP when you see these codes, CMS says in CR 11855: Group Code “CO” and Claim Adjustment Reason Code (CARC) “95” with message “Plan procedures not followed.”

10. Educate. There are many moving pieces to this change, and you need to make sure your relevant staff members are up on them. “Educating … staff on the lesser RAP submission requirements is critical in order not to hold up the RAPs,” Labarta emphasizes.

In these last weeks, agencies should be “learning from their EMR vendor the triggers for billing and processing the no-pay RAPs, understanding the impact to related revenue recognition, and preparing to adapt to new workflows, as needed,” Little recommends.

11. Be conservative with expenses. The cash flow crunch when agencies transition to no-pay RAPs may be deadly if you’re not careful. “Be careful with outflows,” Olson counsels. This “might not be a good year for bonuses,” for example, he offers.

12. Get your financial resources in order. HHAs may not expect a financial bailout on the order of the initial COVID-19 relief funding. But more COVID-related support is likely on the way. “Prepare your PPP application for the next round of COVID relief,” Olson advises of the CARES Act Paycheck Protection Program.

In the same vein, “shore up your line of credit,” Olson adds.

Note: CR 11855 with the no-pay RAP provisions is at www.cms.gov/files/document/r10403CP.pdf.