Imperatives for HHAs and Upcoming CareVoyant Software Enhancements

Understanding PDGM No-Pay RAP Rules

CMS introduced the Patient-Driven Grouping Model (PDGM) payment model for Home Health Prospective Payment System (HH PPS) starting January 1, 2020. Beginning January 1, 2021, home health agencies (HHAs) will be required to submit a Request for Anticipated Payment (RAP) before filing each claim. CMS will pay the RAP at 0 percent. The Centers for Medicare & Medicaid Services (CMS) finalized the No-pay RAP policy in the CY 2020 Home Health Prospective Payment System Rate Update rule.

Although there is no payment assigned to the RAP, it still serves an operational role for the Medicare program by establishing the beneficiary’s primary home health agency (HHA) in the Common Working File (CWF) to enforce the consolidated billing rules. CMS has modified the criteria for submitting RAP beginning January 1, 2021.

CareVoyant will be implementing software enhancements to accommodate No-Pay RAP to help Home Healthcare Agencies effectively manage No-Pay RAP.

Also read our blog titled Home Health Care Agencies: Are you ready for PDGM?, for more information on PDGM readiness for home healthcare agencies.

CMS No-Pay RAP Changes

Because there is no payment assigned to the No-pay RAP, CMS has modified the criteria for submitting RAP beginning January 1, 2021, to require the following:

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 Caregiver should make the initial visit within the 60-day certification period and admit the individual to a home healthcare facility.

Timely Submission Requirements

Additionally, for CY 2021, CMS established a non-timely submission payment penalty when the HHA does not submit the RAP:

Within five(5) calendar days from the start of care date for the first 30-day period of care in a 60-day certification period, and
Within five(5) calendar days of the “from date” for the second 30-day period of care in the 60-day certification period

This reduction in payment will be equal to a 1⁄30 reduction to the wage and case-mix adjusted 30-day period payment amount for each day from the home health “from date” until the date the HHA submits the RAP. The penalty applies to outlier claims and LUPA (low utilization payments adjustment) claims.

For LUPA 30-day periods of care in which an HHA fails to submit a timely RAP, CMS will not pay for LUPA claims that occurred on days that fall within the period of care before the submission of the RAP. The payment reduction cannot exceed the total payment of the claim.

5 day submission timeline for PDGM No Pay RAP.png

5-Day RAP Submission Time Frame - Processes Home Care Agencies must follow

The Five(5)-day submission time frame and the late submission penalty have caused concern for many agencies. The current requirements for submitting the RAP necessitate several processes to be conducted, such as:

A complete plan of care to be sent to the physician,
A comprehensive assessment including the OASIS to establish the POC and generate an accurate HIPPS code, and
All certification requirements are to be completed before submitting the RAP in case the plan of care includes the certification statement.

With the modified criteria, Home Health Agencies will have to have the physician order in place and the initial visit completed. There is no need to complete the OASIS and Plan of Care before sending RAP.

Compliant No-Pay RAP Process changes for Agencies:

Home Health Agencies will need to modify agency operations and the electronic health record (EHR) to accommodate the revised PDGM criteria in 2021. The main goal for agencies should be the timely submission of RAP without incurring a late submission penalty.

Software platforms will have to be adjusted to accommodate the new PDGM billing process. The following are some of the requirements:

Adjust the RAP claim process to submit the RAP in compliance with the new criteria
Provide alerts about the status of the RAP and enough information to make sure RAP get sent within five (5) days.
Provide an option to create late RAP adjustments automatically during the final bill.

Upcoming CareVoyant Software Enhancements for No-Pay RAP

CareVoyant will be implementing the following software enhancements to help Home Healthcare Agencies to stay efficient and compliant with the new PDGM changes.

RAP Claim Process: CareVoyant will adjust the RAP claim process to initiate the processing of RAP claims upon the issuance of the initial order and completion of the first visit.
PDGM Billing Manager: CareVoyant will provide alerts with the requisite information to enable agencies to monitor and process RAP claims on time.
PDGM Monitor: CareVoyant will provide alerts with the requisite information to monitor the status of RAP claims.
Final Claim Process: CareVoyant will modify the Final claim process to adjust for late RAP payment reductions automatically.
RAP Exception Report: CareVoyant will provide an exception report listing all payments periods without a RAP.

ABOUT CAREVOYANT

CareVoyant is a leading provider of cloud-based integrated enterprise-scale home health care software that can support all home-based services under ONE Software, ONE Patient, and ONE Employee, making it a Single System of Record. We support all home based services, including Home Care, Private Duty Nursing, Private Duty Non-Medical, Home and Community Based Services (HCBS), Home Health, Pediatric Home Care, and Outpatient Therapy at Home.

CareVoyant functions – Intake, Authorization Management, Scheduling, Clinical with Mobile options, eMAR/eTAR, Electronic Visit Verification (EVV), Billing/AR, Secure Messaging, Notification, Reporting, and Dashboards – streamline workflow, meet regulatory requirements, improve quality of care, optimize reimbursement, improve operational efficiency and agency bottom line.

For more information, please visit CareVoyant.com or call us at 1-888-463-6797.