Billing and Cash Flow Changes Likely to Hit HHAs Sooner Than Expected

Posted on 18 Mar, 2019 |comments_icon 0|By Rebecca L. Johnson

Are RAPs on a going-going-gone trajectory? It sure looks like it.

Your billing department will have its hands full with the Patient-Driven Groupings Model (PDGM) changes slated for next year. But all signs suggest more is yet to come — and come soon — which will surely impact your cash flow.

A new RAP suppression instruction shows why home health agencies shouldn’t count on the advance payments sticking around much longer — and that goes for all HHAs.

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.”

While the MLN Matters article does not specify, multiple experts predict that the ruling refers to HHAs enrolling after the date of the article (Feb. 10 or later). Quite possibly, though, it includes agencies enrolling in all of 2019, since they’re the ones already designated not to receive RAPs under the PDGM.

The enhanced oversight “provisional period will include a suppression of all Request for Anticipated Payment (RAP) payments for 30 days to 1 year,” CMS states. “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.”

Shock & Speculation

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 PDGM reform that takes effect in 2020, those HHAs were expecting 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.”

William Dombi, president of National Association for Home Care & Hospice, suspects that “CMS considers this to be their substitute for the lifting of the moratoria.”

Background: CMS posted a notice to its website, noting that “as of January 30, 2019, there are no active Medicare Provider Enrollment Moratoria in any State or U.S. territories. The Provider Enrollment Moratoria Waiver Demonstration will end when the moratoria expires.” At least one HHH Medicare Administrative Contractor, Palmetto GBA, also has posted the notice on its website.

But could the enhanced oversight and suppression be CMS’s shortcut to get rid of advance payments, as others suspect? The agency has already eliminated RAP payments for new agencies under PDGM and solicited comments in the 2019 proposed rule on cutting RAP payments altogether.

Industry veterans aren’t quite buying CMS’s claim that “the provisional period of enhanced oversight authority … is unrelated to a recently published Medicare final rule” that implements PDGM.

“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.”

“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.”

In apparent endorsement of Markette’s suspicion, CMS doesn’t indicate how it will determine the period of suppression of RAP payments for newly enrolling providers. Consultant J’non Griffin, owner of Home Health Solutions in Carbon Hill, Alabama, says, “My own specific gut feeling is that they will be long enough to carry into PDGM, where they will not receive RAP payments if they are a new agency after Jan. 1, 2019.”

If all RAP suppressions aren’t made to run into PDGM, Little doesn’t expect CMS to make its criteria for determining the length public.

And here’s the rub. While newly enrolling agencies won’t be eligible for RAP payments, they still must submit the claims. “The HHA still needs to submit a RAP for each home health episode in order for the final claim to be processed,” CMS instructs in the MLN Matters article. “New HHAs that are subject to RAP suppression will receive the appropriate, total payments for their services for each particular home health episode after the submission of a final claim.”

Will RAPs Get the Axe?

You can expect CMS’s lack of RAP support to translate into RAP elimination for all HHAs, 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 to be released 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.

Learn More

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Rebecca L. Johnson
Executive Editor, Newsletters

Rebecca has covered the ever-evolving home health and hospice markets for 20 years, starting about the time the Balanced Budget Act ushered in the devastating Interim Payment System. Under a myriad of payment and regulatory changes, Rebecca has helped home health agencies and hospices thrive and stay compliant. She has also covered markets ranging from internet banking to managed care to physicians. She is an expert on legislation, regulation, reimbursement, operations, business strategies, and more. Rebecca received her Bachelor of Science degree from University of Illinois Urbana-Champaign.

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