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LUPAs thresholds to vary under PDGM.<\/strong><\/em><\/span><\/p>\n The home care industry may hate the idea, but CMS is pushing ahead with its proposal to phase out Requests for Anticipated Payment under the newly proposed Patient-Driven Groupings Model.<\/p>\n When the\u00a0Centers for Medicare & Medicaid Services\u00a0<\/strong>issued basically the same payment reform model last year as the Home Health Groupings Model, it \u201csolicited comments on the possibility of phasing out the split percentage payment approach in the future,\u201d CMS notes in its 2019 Home Health Prospective Payment System proposed rule that contains the re-proposed revamp. \u201cCommenters did not provide suggestions for a phase-out approach.\u201d<\/p>\n Despite the fact that HHGM \u201ccommenters generally expressed support for continuing the split percentage payment approach in the future under the proposed alternative case-mix model,\u201d according to the rule, CMS continues to advance the idea of eliminating RAPs. \u201cAs a result of the reduced timeframe for the unit of payment \u2026 a split percentage approach to payment may not be needed for HHAs to maintain adequate cash flow,\u201d CMS argues.<\/p>\n The rule cites some stats to support the agency\u2019s position. \u201cCurrently, about 5 percent of requests for anticipated payment are not submitted until the end of a 60-day episode of care and the median length of days for RAP submission is 12 days from the start of the 60-day episode,\u201d CMS says. \u201cAs such, we are reevaluating the necessity of RAPs for existing and newly-certified HHAs versus the risks they pose to the Medicare program.\u201d<\/p>\n CMS also cites a few extreme fraud cases to support its assertion that \u201cRAP payments can result in program integrity vulnerabilities\u201d (see below<\/em>).<\/p>\n Instead, CMS\u2019s examples show how incompetent the agency and its contractors were in using their existing tools to detect and stop the fraud, maintains attorney\u00a0Robert Markette Jr.\u00a0<\/strong>with\u00a0Hall Render\u00a0<\/strong>in Indianapolis. When a large portion of an agency\u2019s RAPs fail to have corresponding end of episode claims filed, Medicare can suspend the offending agency\u2019s payments, Markette points out.<\/p>\n If CMS eliminates RAPs, it will be punishing law-abiding providers instead of targeting criminal enterprises like those it cited in the rule, Markette says.<\/p>\n Plan on it:<\/span>\u00a0<\/strong>Given how persistent CMS is with the idea of scrapping RAPs, HHAs can be pretty certain that \u201cRAPs are going away\u201d in the next few years, Markette predicts. Smart agencies will plan for the change and prepare now, he advises.<\/p>\n In the rule, while CMS says it won\u2019t suggest cutting RAPs for existing HHAs now, it is \u201csoliciting comments on reducing the percentage of the upfront payment incrementally over a period of time.\u201d<\/p>\n Newly enrolling HHAs are not so fortunate. CMS proposes \u201cnot to allow newly-enrolled HHAs, that is HHAs certified for participation in Medicare effective on or after January 1, 2019, to receive RAP payments beginning in CY 2020.\u201d It also proposes requiring them to submit a \u201cno-pay RAP\u201d to establish a home health benefit period in the system.<\/p>\n Plus:<\/span>\u00a0<\/strong>\u201cIf in the future the split percentage approach was eliminated, we are also soliciting comments on the need for HHAs to submit a [notice of admission] within 5 days of the start of care to assure being established as the primary HHA for the beneficiary during that timeframe and so that the claims processing system is alerted that a beneficiary is under a HH period of care to enforce the consolidating billing edits as required by law.\u201d<\/p>\n Do this:<\/span>\u00a0<\/strong>Agencies should use the opportunity to comment on the rule to try to change the outcome, Markette and other experts urge.<\/p>\n The changes in the 2019 proposed rule \u201care significant, impacting not only payments but potentially timing of payments,\u201d emphasizes\u00a0The Health Group\u00a0<\/strong>in Morgantown, West Virginia. \u201cHome health agencies need to provide comment on the proposed rule,\u201d the consulting firm counsels.<\/p>\n And this:<\/span>\u00a0<\/strong>\u201cWith the finalization of the proposed rule, assess the potential reimbursement and cash flow impacts that will result,\u201d The Health Group urges in its electronic newsletter. Other billing-related provisions include:<\/p>\n \u201cThe comprehensive assessment would still be completed within 5 days of the start of care date and completed no less frequently than during the last 5 days of every 60 days beginning with the start of care date, as currently required by \u00a7484.55, Condition of participation: Comprehensive assessment of patients,\u201d the rule clarifies. \u201cIn addition, the plan of care would still be reviewed and revised by the HHA and the physician responsible for the home health plan of care no less frequently than once every 60 days, beginning with the start of care date, as currently required by \u00a7484.60(c), Condition of participation: Care planning, coordination of services, and quality of care.\u201d<\/p>\n Instead of the current five-visit threshold for all case mix categories, PDGM would set the threshold at two to six visits depending on the category, the rule explains. Currently LUPAs account for about 8 percent of episodes, while CMS forecasts they will make up 7.1 percent of 30-day episodes under PDGM.<\/p>\n In response to criticism in last year\u2019s HHGM rulemaking, CMS says \u201cwe do not believe that the case-mix-specific LUPA thresholds would result in additional administrative burden as LUPA visits are billed the same as non-LUPA periods.\u201d<\/p>\n Resource:<\/span>\u00a0<\/strong>CMS lists the individual case mix categories\u2019 LUPA thresholds in Table 47 of the rule. Those categories with thresholds higher than the current level (i.e., six visits) include six MS Rehab Early\/Institutional categories and three Neuro – Medium Early\/Institutional categories.<\/p>\n\n
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