The Centers for Medicare and Medicaid Services (CMS) released its final home health payment rule for 2021 on October 29, 2020. We’ve outlined important aspects of the final rule that home health providers need to know to stay informed and keep operations running smoothly.

No Major Payment Changes

Under the proposed final home health payment rule, there are no major changes to payment. As expected, CMS determined there is not adequate data from CY 2020 to make modifications; therefore, there are no changes to the Patient Driven Groupings Model or the model’s controversial behavioral adjustment. The final rule adds an increase of 1.9% in payment for agencies in 2021. LUPA thresholds and case-mix weights will remain the same for CY 2021. The routine statutorily required update to the home health payment rate is set at 2.7%.

In addition, there are no changes to the Home Health Quality Reporting Program (HH QRP). There were, however, 20 measures finalized for CY 2022. These measures will be captured from OASIS items and HHCAHPS.

Billing RAPs

The most substantial change involves the Request for Anticipated Payment (RAP) in 2021. Each 30-day payment period will continue to require a RAP to be filed and processed prior to the final claim; however, there will be no associated up-front compensation. All agencies will be required to submit this ‘no-pay’ RAP within five calendar days after the start of each 30-day period. This also establishes the beneficiary’s primary home health agency in the Common Working File (CWF). This is significant for agencies as there will be a non-timely submission payment reduction for RAPs that are not filed and accepted for processing within those five days.

The reduction in payment will equal one-thirtieth for each day from the home health start of care or the ‘from date’ for subsequent 30-day periods until the date the agency submits the RAP. For Low Utilization Payment Adjustment (LUPA), 30-day periods of care in which an agency fails to submit a timely RAP, no LUPA per-visit payments will be made for visits that occurred on days that fall within the period of care prior to the submission of the RAP. CMS reiterated that this reduction will be a provider liability and billing the beneficiary for the penalty is not allowed.

The home health agency must meet two minimum requirements prior to submitting a RAP beginning in 2021:

  • A verbal order from the physician that includes the services required for the initial visit. This must be signed and dated by the registered nurse or qualified therapist responsible for furnishing or supervising the ordered service in the plan of care that will be signed by the physician
  • Start of care visit is completed and the patient is admitted for home health services

How should agencies prepare?

  • Evaluate and implement agency processes that will trigger timely RAP submission when the two minimum requirements are met.
  • Establish a process with the EMR and billing team to submit subsequent 30-day period RAPs up front.
  • Work with your EMR to ensure all RAP submissions meet Medicare billing requirements for RAP submissions including a valid primary diagnosis code and a valid HIPPS code.
  • Ensure your intake department accurately verifies the patient’s insurance. Agencies will need to know right away if a patient has traditional Medicare in order to meet the 5-day RAP submission deadline.

Wage Index

An updated census resulted in key changes in the Wage Index. This will impact some agencies that service these specific geographical areas. CBSA codes have been restructured, therefore, urban counties may have become rural, rural areas may have become urban or existing CBSAs may have been split. It will be important for agencies to use the latest delineations to maintain a more accurate and up-to-date payment system that reflects the reality of population shifts and labor market conditions.

Telehealth and Plan of Care

The final rule permanently established that the plan of care (POC) must include any provision of remote patient monitoring or other services furnished via a telecommunication system. Despite a provider push for telehealth reimbursement, it reiterates that these services cannot substitute for a home visit ordered as part of the POC or compensated as a billable visit. §409.46(e) is amended to include other communications or monitoring services that are consistent with the beneficiary’s POC. An example of this would be remote patient monitoring that transmits data, such as blood pressure or glucose monitoring. Agencies that provide telemonitoring should ensure the patient’s POC includes these services and describes how the patient’s needs support its use to reach goals.

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