TPL Demand Billing Update: NGS Confirms No-Pay RAP Instructions for All Dual-Eligible Claims as HCA Seeks Official Word From OMIG

Situation Report | June 1, 2021

In late March, HCA informed members of a major expected change in the Third Party Liability (TPL) audit process conducted by the state Office of the Medicaid Inspector General (OMIG).

The change is due to a recent federal no-pay Request for Anticipated Payment (RAP) requirement, as summarized below.

HCA has since received an update from the Medicare Administrative Contractor, National Government Services (NGS), on how to handle no-pay RAPs for TPL purposes, largely confirming instructions given in March by OMIG’s TPL contractor.

The Issue

On January 1, 2021, the U.S. Centers for Medicare and Medicaid Services (CMS) implemented a no-pay RAP requirement. This policy change includes payment penalties for submitting no-pay RAPs later than 5 days after the start of care (SOC) or admission date.

This requirement complicates New York State’s retrospective TPL initiative, which requires providers to demand-bill Medicare for prior periods, long after the 5-day deadline for providers to also submit a timely no-pay RAP. And if a no-pay RAP is submitted after 30 days, Medicare won’t pay a demand-billed claim, even if Medicare is determined to be the appropriate payor.

Only at the end of March did the state’s TPL contractor, University of Massachusetts Medical School (UMMS), inform HCA that this issue involving no-pay RAPs would require a change in provider billing practices going forward in order to fulfill the objectives of retrospective TPL audits.

UMMS has indicated that a no-pay RAP must be submitted to NGS for all dually eligible cases, even for those cases where the Medicare-certified agency makes a determination that the dually eligible beneficiary does not meet the Medicare criteria for home health (for example: no skilled need or not homebound) and decides that Medicaid is the proper payor. This will need to be done within five days from the SOC or admission date, to avoid future payment penalties.

What NGS Says

NGS has now largely confirmed UMMS’s instructions.

In a message to HCA last week, NGS representative Christa Shipman states the following:

If the HHA waits until Medicaid requests billing [for TPL purposes], the 5 calendar day requirement wouldn’t be met. Because there’s no payment or auto-cancelation of RAPs, HHAs should submit RAPs for their dually-eligible patients, even if they’re not sure which ones Medicaid will request billing. If the claim doesn’t get submitted, there’s no penalty, and if Medicaid does request the HHA to bill, at least the RAP(s) will already be in the system. This is for any home health services provided to a dually-eligible beneficiary in Calendar Year 2021.

HCA Again Requests Formal Confirmation from OMIG, UMMS

As we noted in the April 5 Situation Report, HCA met with OMIG officials and requested formal instructions published on official OMIG or UMMS letterhead confirming these instructions. Given what NGS has now said, we’ve reasserted our call for a formal confirmation from OMIG/UMMS that agencies should submit a no-pay RAP for all dual-eligible claims.

HCA: Hold CHHAs Harmless for Periods When They Were Unaware of the New Procedures

We also again urge OMIG to refrain from penalizing CHHAs if the CHHAs did not submit no-pay RAPs to Medicare for TPL appeal cases involving claims between January 1, 2021 through March 31, 2021 — a period of time when CHHAs were not made aware of the new procedures. HCA also requests that OMIG extend this “hold-harmless” provision through May 31.

HCA asserts that OMIG must not attempt to recoup previously paid Medicaid claims from providers in cases where OMIG is seeking a TPL appeal and where Medicare will not pay due to late submission of no-pay RAPs.

HCA has already reasserted these requests to OMIG and will continue to press our concerns. Please stay tuned for further updates.