Beginning January 1, 2021, the Centers for Medicare & Medicaid Services (CMS) is ushering home health into the era of paying for services rendered, instead of up-front payment. This change has been a goal for CMS for the past several years, as home health is the last of the healthcare providers to switch to payment after services are rendered.

With this model change on the horizon, home health agencies must adjust processes. As with any change, the switch to payment after services rendered raises many questions for the home health agency (HHA).

What do we need to know now? 

CMS has lessened the requirements for the HHA to submit a Request for Anticipated Payment (RAP), as there will no longer be a payment associated with the RAP, but a late submission penalty has been added. The sole purpose of the RAP, effective January 1, 2021, is to establish your HHA as the primary HHA for the beneficiary. The following is required to submit a RAP effective January 1, 2021:

  • The appropriate physician’s written or verbal order that sets out the services required for the initial visit has been received and documented, as required in regulation at 42 CFR 484.60(b) and 42 CFR 409.43(d).
  • The initial visit within the 60-day certification period must have been made and the individual admitted to home health care.

Since the beginning of Patient Driven Grouping Model (PDGM), Medicare has been calculating the HIPPS code used for payment instead of using the HIPPS code listed on the claim as a basis for payment.  For periods of care on or after January 1, 2020, grouper software is incorporated in Medicare claims processing systems calculated the Health Insurance Prospective Payment System (HIPPS) code for payment. Grouper uses claims data and OASIS data from the CMS quality data repository to assign the appropriate HIPPS code for payment.

For RAPs with “from” dates on or after January 1, 2020, the HHA may submit the HIPPS code they expect will be used for payment if they choose to run grouping software at their site for internal accounting purposes. If not, they may submit any valid HIPPS code in order to meet this requirement. Beginning January 1, 2021, the HIPPS code will be used to match the RAP to the claim in order for CMS to determine if the RAP was submitted in a timely fashion. The HIPPS code will be required to match both the RAP and the claim. RAPs with “from” dates on or after January 1, 2021 are paid zero percent with the total payment for the period of care made on the corresponding claim.

The service date is required on the RAP for initial episodes/periods of care; the HHA reports on the 0023 revenue code line the date of the first covered visits provided during the episode/period. This holds true for subsequent episodes, as well. CMS has identified an exception to the date of the first covered visit for subsequent episodes/periods in calendar year (CY) 2021. The HHA may submit these RAPs with the first day of the period of care as the service date on the 0023 line to allow for RAP submission of two 30-day payment periods and to prevent the delay with RAP submission for subsequent episodes/periods of care when the first visit in that period would be beyond the five-day timeframe for a timely-filed RAP.

A principal diagnosis code is required on the RAP, a requirement of the HIPAA standard claim format, and the Medicare program cannot change the requirement. The secondary diagnoses are optional on the RAP. CMS confirmed to McBee that the primary diagnosis on the RAP and the claim do not have to match and there will be no Medicare edits regarding the diagnosis. CMS also confirmed there will be no Medicare edits performed between the primary diagnosis/clinical grouping and second character of the HIPPS code. In other words, if the primary diagnosis is a cardiac diagnosis, the second character of the HIPPS code does not have to be “H,” indicating MMTA: Cardiac.

How can an EMR ready the HHA for this change? 

It is imperative to have open conversations with your EMR vendor about readiness. Will your software vendor be able to expedite the RAP process by ensuring the HIPPS code on the RAP matches the HIPPS code on the claim, even after review of the OASIS accuracy has been completed?

Currently, most home health electronic medical record (EMR) software will calculate an accurate HIPPS code based on the OASIS and diagnosis within the EMR. If your EMR requires an ICD-10 diagnosis code to advance the chart to an admission status, this same ICD-10 code can be used on your RAP and the EMR could assign any valid HIPPS code for the RAP submission. Once your RAP is submitted within the five-day window, you can continue your internal review process for OASIS accuracy and ICD-10 coding.  Software vendors will need to duplicate the HIPPS on the RAP to the claim and provide the accurate HIPPS assignment for accounting purposes.

How will this change impact operations and cash flow?

As mentioned above, ensure your EMR vendor is able to duplicate the HIPPS on the RAP and the claim and also provide an accurate HIPPS to determine potential reimbursement and LUPA thresholds.

If the RAP is not submitted within five days, the HHA will receive a reduction in the payment that is equal to a 1/30th reduction to the wage and case-mix adjusted 30-day payment period for each day from the home health “from” date until the HHA submits the RAP.

For periods of care beginning on and after January 1, 2021, all RAPs are paid zero percent.

If an HHA fails to file a timely-filed RAP, it may request an exception, which if approved, waives the consequences of late filing. The four circumstances that may qualify the HHA for an exception to the consequences of filing the RAP more than five calendar days after the HH period of care “from” date are as follows:

  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 A/B MAC (HHH) 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 is awaiting its user ID from its A/B MAC (HHH)
  4. Other circumstances determined by the A/B MAC (HHH) or CMS to be beyond the control of the HHA

RAPs with “from” dates on or after January 1, 2021 will no longer be automatically canceled because there will be no payment to recoup.

Determine the best approach to implement any changes within your current processes. The HHA software will need to be able to place a preliminary HIPPS on the RAP/Final Claim while still calculating accurate revenue for financial tracking.

What will the future hold for CY 2022 with the implementation of the Notice of Admission (NOA)? 

CMS proposes to align the No-Pay RAP with the one-time NOA which begins January 1, 2022. CMS has not finalized the data content for the NOA and plans to release a companion guide when the NOA data content has been finalized.

Other No-Pay RAP Resources:

CMS – CY 2021 HH PPS Final Rule

NAHC – The “No Pay RAP” Fact Sheet and Frequently Asked Questions

CGS – Submitting a Request for Anticipated Payment (RAP) under the Home Health Patient-Driven Groupings Model

Change Request 11855 – https://www.cms.gov/files/document/r10369cp.pdf

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