Situation Report | September 13, 2021
HCA to Discuss Potential Problems with New Guidance with OMIG and NGS
The state Department of Health (DOH) issued its August Medicaid Update, which includes the following story on new billing requirements for Certified Home Health Agencies (CHHAs) involving dual-eligible beneficiaries as it relates to the state’s home health Third Party Liability (TPL) initiative, which is overseen by the state’s Office of the Medicaid Inspector General (OMIG):
On January 1, 2021, the U.S. Centers for Medicare and Medicaid Services (CMS) implemented a new Medicare billing requirement for Home Health Agencies (HHAs) requiring a No-Pay Request for Anticipated Payment (RAP) for all dual-eligible Medicare/Medicaid recipients prior to billing each final claim. The No-Pay RAP must be submitted within five calendar days after the start of care date for the first 30-day period of care in a 60-day certification period and within five calendar days after the “from date” for the second 30-day period of care in the 60-day certification period. This CMS billing requirement must be satisfied for all dual-eligible Medicare/Medicaid recipients even if the final claim is not intended to be billed to Medicare. Effective immediately, all HHAs must submit No-Pay RAPs to Medicare for all services rendered to dual-eligible Medicare/Medicaid recipients.
The Office of the Medicaid Inspector General (OMIG) has contracted with the University of Massachusetts Medical School (UMMS) to perform Home Health Medicare Maximization Services. This contract seeks to maximize Medicare reimbursement for dual-eligible Medicare/Medicaid recipients who have received home health care services paid by Medicaid. Under this OMIG project, CHHAs may be directed to demand bill claims to Medicare to ensure Medicaid remains the payor of last resort.
The OMIG and UMass will be issuing new Demand Bill Directives in September 2021 to inform CHHAs which claims require a Medicare demand bill submission. The dates of service included in the upcoming review period overlap with the start of the new CMS No-Pay RAP billing requirements that began on January 1, 2021. CHHAs should have initiated a No-Pay RAP prior to receipt of the Demand Bill Notice (although there was no official guidance to do so until this announcement).
If the No-Pay RAP was not submitted in compliance with the new Medicare billing requirement for any period of care on the Demand Bill Directive, the CHHA should take the following three steps:
- Submit a No-Pay RAP to CMS for all identified dates of service;
- File a Demand Bill final claim with a KX modifier and indicate within the Remarks section of the claim “late RAP due to Medicaid TPL demand billing request”; and
- Follow all outlined instructions within the Demand Bill Directive pertaining to timely and complete submission of information and documentation to UMMS.
CMS is allowing the above steps as a temporary fix for the submission of demand bills for which No-Pay RAPs were not previously submitted.
HCA is deeply concerned with the news issued in the August Medicaid Update regarding CMS implementing this new Medicare billing requirement when providing services to dual-eligible beneficiaries.
CMS’s requirement for CHHAs to submit No-Pay RAPs for all dually-eligible beneficiaries (going forward) for services provided in Calendar Year 2021, even when the CHHA believes Medicaid is the appropriate payor, is not only administrative burdensome, but will also cause problems with the Medicare Common Working File. Therefore, some other Medicare providers/entities (i.e. durable medical equipment and outpatient therapy providers) will expect Medicare reimbursement from the CHHA, even in cases where the CHHA plans to bill Medicaid for services.
HCA will be discussing these issues with representatives from the state OMIG and UMMS, as well as with representatives from CMS and National Government Services (NGS). HCA will update CHHA members as additional information becomes available.
For questions or concerns, please contact Patrick Conole.