Billing and revenue exchange is one of the biggest issues for home health agencies across the nation. Without processes in place, agencies face challenges of timely billing and delayed payments. In the near future, agencies must expertly examine and fine tune their auditing and billing policies to ensure that RAPs (Request for Anticipated Payment) and final claims are billed within Medicare’s timelines, or they face devastating consequences.
Palmetto GBA (Government Benefits Administration) recently published an article outlining measures that will be taken to ensure compliance with timely billing for Jurisdiction 11 Home Health Agencies. J11 includes the states of Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee and Texas. For these states, and potentially all states as other MACs (Medicare Administrative Contractors) follow suit, the possibility of getting ZERO funds on RAPs is a real threat.
The Home Health industry has been warned for years that MACs were paying attention to timely filing guidelines, and that agencies could be penalized in the future for excessive RAP take-backs. Palmetto GBA routinely examines data on RAPs and FINAL bill submissions to determine the total number of auto-cancelled and provider-initiated cancellations versus the total number of final claims processed. Since MACs have the authority to revoke a providers privilege to receive payment on a RAP, agencies who have excessive numbers of cancellations face the reality of no longer having the privilege of being paid in advance of care delivery to their Medicare beneficiaries.
Agencies who are at risk of having RAPs suppressed will receive notification from PGBA before they are set to pay at zero payment. This is so that agencies realize their current practice is unacceptable and their billing is being monitored. If improvement is not noted within a reasonable amount of time, they will be further notified that their RAPs will be set to process with zero payment. Once this happens, agencies will have to jump through several hoops which are not guaranteed to immediately reinstate their RAP privileges. For example, agencies on the zero payment RAP list will have to submit a Corrective Action Plan (CAP) containing:
-Statement of the problem or weakness that caused the delay in timely filing of FINAL bills
-Proposed solutions to the stated problem(s)
-Who is responsible for monitoring the problem(s)
-Any other important information that is helpful
The purpose of the CAP is to ensure that the agency is aware that CMS regulations must be followed. Once the CAP is submitted from the agency to Palmetto, it will be reviewed. For at least three consecutive months, continued review of the percentage of RAPs vs. FINALS will occur before reinstatement is possible. This three-month period may be extended until the agency can demonstrate an improvement in reducing the number of RAPs cancelled. The current threshold for restoration of RAP payment is less than 25 percent RAPs cancellation.
How Agencies Should Monitor RAPS and Prevent Zero Payment Penalty
1) Know timelines for submission of Final bills
Timeline is the greater of these two:
– 120 days after start of the episode OR
– 60 days after paid date of RAP
2) Look for cancelled RAPS on the Remittance Advice
Type 328 or 338
3) Use Direct Data Entry (DDE) and Online Provider Services (OPS) to monitor status of RAPs and Claims (Final Bills)
4) Monitor outstanding RAPs to ensure final claim/final bill is submitted timely
5) Refine agency processes that are not working
6) Use a calculation formula to assist in determining the frequency of RAP cancellations:
Example One:
June 1 to June 30
Total RAPs cancelled = 5
Total FINALS processed = 25
% RAP cancels vs. Total FINAL claims = 20%
Example Two:
July 1 to July 31
Total RAPs cancelled = 15
Total FINALS processed = 25
% RAP cancels vs. Total FINAL claims = 60%
Revenue management is crucial for agency survival. The threat of zero payment RAPs is real, and action should be taken before the agency is notified by Palmetto of non-compliance. Billing managers and Administrators should closely monitor the submission of RAPs and Final claims. By following these simple measures, agencies can put policies in place to ensure revenue is available to care for the deserving Medicare beneficiaries when needs arise. More information can be found on billing policies here:
http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Jurisdiction%2011%20Home%20Health%20and%20Hospice~Articles~Home%20Health~9ADQ2M3072?open&navmenu=Articles||||
CMS Internet Only Manual (IOM), Publication 100-04, Chapter 10, Section 10.1.12 and 40.1
