Background- What is No Pay RAP?
As if things weren't complicated enough between PDGM and COVID, CMS issued a new rule which has thrown many home health agencies for a loop. For many years, CMS allows agencies to submit a RAP, which means Request for Anticipated Payment. Prior to PDGM implementation in 2020, a RAP was 60% of the anticipated payment over 60 days up front and then the remaining 40% at the final bill. The helped agencies with cash flow to cover the cost of care during the 60 day episode. With PDGM and CMS No Pay RAP, agencies are concerned.
In 2020, CMS reduced the RAP to 20% of the anticipated payment at the beginning of the episode and 80% at the final bill. However, under PDGM, there are now two 30 day billing periods instead of one 60 day period.
RAP 2021- What is a RAP claim?
One of the biggest misconceptions of RAP process in 2021 is actually the name. Beginning in 2021, there will be no payment associated with a RAP. In effect, the RAP is simply establishing care with a home health agency. In terms of managed care, a RAP is how home health is authorized and establishes the episode. It resembles much closer to the process in hospice that is a Notice of Election (NOE)- which informs CMS that hospice care will be starting.
There are big changes from RAP in 2021 vs 2020.
Here is what is required for RAP in 2021: 1- Verbal or written order (must be documented) for home health care. 2- First billable visit complete. 3- HIPPS code (any valid HIPPS code will work- must match at RAP and final billing) 4- Any PDGM compliant diagnosis code. (Best practice would be to use a code out of the appropriate grouper (cardiac patient, cardiac code), but any will work as long as the codes match on final billing.
Here is where a BIG departure from the previous process. Agencies only have 5 days to submit a RAP and it must be ACCEPTED by the MAC. If the RAP is submitted late, then a penalty of 1/30 of the 30 day calculated payment. Here's how it will work: Say a patient reimbursement is $2800. If you divide that by 30 days, that comes to a daily rate of $93.33. If a RAP is submitted on day 6, there would be a penalty of 6/30's of the reimbursement rate. The penalty would be $560 for a late RAP submission. That means, get the RAP in! You can submit a RAP for both early and late episodes at the same time. This saves a lot of time and administrative burden.
In the case of LUPAs and RAPs. If a RAP is not submitted timely, in the case of a LUPA, any visit made prior to the RAP submission will not be paid. YIKES!
Here are two great links to videos that explain things also.
Q: How will the HIPPS code be determined on the RAP if the OASIS is not required to be complete?
A: This HIPPS code reported on the RAP is no longer required to match the HIPPS code calculated on the assessment. ANY valid HIPPS can be reported. If you have a grouper that can generate a HIPPS code, that can work. But any valid HIPPS code will work.
Q: Are there any changes to the automatic RAP cancellation process?
A: RAPs will no longer be subject to auto cancellation.
Q: What are the changes to the first billable visit requirement?
A: The first billable visit for the episode will satisfy the requirement for both the first and second 30-day billing period RAPs.
Q: What Diagnosis Codes (DX codes) need to be reported on RAPs?
A: Only principal diagnosis (DX) is required. For from dates after January 1, 2021, the ICD code and principal diagnosis used for payment grouping will be claim coding rather than the OASIS item. As a result, the claim and OASIS diagnosis codes will no longer be expected to match in all cases. Typically, the codes will match between the first claim in an admission and the start of care (Reason for Assessment- RFA 01) assessment and claims corresponding to recertification (RFA 04). Second 30-day claims in any 60-day period will not necessarily match the OASIS assessment. When diagnosis codes change between one 30-day claim and the next, there is no absolute requirement by the HHA to complete an "other follow up" (RFA 05) assessment to ensure that diagnosis coding on the claim matches the assessment. However, the HHA would be required to complete an "other follow up" (RFA 05) assessment when such a change would be considered a major decline or improvement in the patient's health status.
Here is a Link to a flyer from CMS on No Pay RAP. CMS No Pay RAP overview