The truth about RAPs under PDGM

Is CMS doing away with RAPs? Will there be multiple RAPs under PDGM? Here's what is and isn't true

As home health providers try to make sense of the complex new payment methodology Medicare will implement in January 2020, one of the areas of confusion centers around reimbursement paid in advance of the final claim submission.

“One of the common questions agencies have is how Requests for Anticipated Payment, or RAPs, will work under the new Patient-Driven Grouping Model,” said J’non Griffin, owner and president of Home Health Solutions.

Under the current payment system, agencies submit a plan of care outlining the services they will provide over a 60-day episode of care, and receive partial reimbursement based on expected use of resources. The rest of the payment is made once the final claim has been submitted.

Many home care agencies are questioning how this process will work under PDGM, J’non said.

“Agencies are hearing that RAPs are going away, and they’re also hearing that there will be multiple RAPs under PDGM,” she said. “It’s understandable that there is a great deal of confusion going on right now about PDGM because this is a complex new payment model and there is a great deal to take in. PDGM will usher in operational changes of a magnitude home health hasn’t seen in two decades.”

Here’s J’non’s wrap-up on what is and what isn’t true about RAPs under the new Medicare payment model.

Are RAPS going away?

“RAPs are not going away just yet," J’non said. “But CMS may be moving in that direction. What agencies are hearing about RAPs going away refers to a change which will come about under PDGM for new home health agencies. If they are newly enrolled in Medicare during the 2019 calendar year, they will not receive split percentage payments once PDGM takes effect in 2020. ”

Although agencies newly enrolled in Medicare will not receive split percentage payments in 2020 under PDGM, they will still need to submit no-pay RAPs at the beginning of each 30-day billing period.

“They will be required to submit a no-pay RAP every 30 days for subsequent periods as well,” J’non said.

Will there be multiple RAPs? “Because the billing period will shorten to 30 days under PDGM, there will be more than one RAP for a full 60 day episode of care under PDGM,” J’non said. “There will be one RAP for each 30-day billing period. Agencies will submit a RAP at the beginning of each 30-day period, and then submit the final claim at the end of each 30-day period.”

For a standard 60-day episode of care, an agency would submit two RAPs under PDGM, one for the first 30-day period and a second for the next 30-day period.

What will the split percentage payment be? Under PDGM, the split percentage payment will be 60/40 for the first 30-day period of care and 50/50 for all subsequent periods, J'non said.

How will changes in variables affect RAPs? New PDGM payment methodology is a complex system of interlocking variables, including the patient’s admission source. A patient may be considered either an institutional admission source if he or she was admitted to home health within 14 days of an acute or post-acute in-patient stay, or a community admission source for all other admissions.

CMS will only adjust admission source for the final home health claim submitted.

If a RAP is submitted and paid as a community admission source and then an acute or post-acute Medicare claim is submitted for that patient prior to the final home health claim, the RAP will not be adjusted, J’non said. Only the final home health claim would be adjusted to reflect the institutional admission.

Home care providers will use occurrence codes on their final claims to indicate admission source, but occurrence codes will not be used for RAPs. Stay in the PDGM loop! Need more PDGM explanation and advice? Subscribe to our free weekly newsletter, Complete Compliance SOLUTIONS, for weekly articles like this one. Get J'non's helpful PDGM tips in your inbox each Monday. Sign up here.