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September 13, 2018

Monitoring Misuse of Home Health Request for Anticipated Payments (RAPs)

According to the Centers for Medicare & Medicaid Services (CMS), under the Home Health Prospective Payment System (HH PPS), a RAP and a final claim are submitted for each 60-day episode period.  Medicare makes a split percentage payment for most HH PPS episode periods. The first payment is in response to a processed RAP, and the last is in response to a processed final claim. If the final claim is not received 120 days after the start date of the episode or 60 days after the paid date of the RAP (whichever is greater), the RAP payment will be canceled automatically by the Fiscal Intermediary Standard System (FISS). For additional information, refer to section 40.1 of the Medicare Claims Processing Manual (CMS Pub. 100-04, Ch. 10)External PDF

Effective, September 17, 2018, as instructed by CMS, CGS will routinely monitor FISS claim data to prevent instances of potential fraud, waste, and abuse. Such instances should be rare and includes, but is not limited to:

  • The number of final claims submitted is less than the number of RAPs submitted generally;
  • The number of final claims submitted late resulting in RAPs being auto-canceled; and
  • Other behavior/misuse causing a level of concern.

CGS will monitor FISS claim data for a reasonable period of time. When monitoring identifies potential misuse any of the following steps may be taken.

  • Education;
  • Corrective Action Plan (CAP);
  • RAP suppression; and/or
  • Referral to the Unified Program Integrity Contractor (UPIC).

CGS will notify the HHA of the action taken and the next steps, upon completion of the monitoring period.

Home health providers should have internal processes and controls in place to ensure they meet CMS requirements related to RAP submissions.

For additional information, please refer to the Change Request 10789External PDF, New Instructions for Home Health Agency Misuse of Requests for Anticipated Payments.

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