New HHA’s under Provision Period of Enhanced Oversight

According to MLN Matters Number SE19005, release date February 15, 2019 new home health agencies in Medicare programs will be placed under a provisional period of enhanced oversight. What does that mean for you and your business?

The new statute focuses on Requests for Anticipated Payments (RAPs) from home healthcare agencies. The Centers for Medicare and Medicaid services (CMS) seeks enhanced oversight for new home health agencies in order to reduce instances of fraud, waste, and abuse.

What does “enhanced oversight” mean?

For new home health agencies, the professional oversight period restricts payments of RAPs for anywhere from 30 days to one year. That means that as a new agency, you will no longer receive “upfront payments” prior to the beginning 60 day episode of home healthcare services.

A RAP will still need to be submitted, however, payment will not be made until the final claim has been billed.

How long will you be under the enhanced oversight? It depends. CMS or one of its contractors will notify you in writing. That notice will provide basic information regarding your provisional period and other information including:

  • The effective for the HHA and when it will end for the provisional period of enhanced oversight.
  • Notification that during the provisional period of enhanced oversight, RAP payments will be “suppressed” or in more simple terms, placed on hold.
  • Emphasis that you – the HHA – are still required to submit an RAP for every home health episode in order for processing of the final claim. (They will be collected and held until final claim is submitted).

Again – HHAs will receive appropriate and full payments for services for each home health episode following the submission of their final claim.

The new ruling follows guidelines of the ACA §6401(a)(3) of the ACA and §1866(j)(3) of the Social Security Act regarding agreements with service providers and enrollment processes.

The goal of the new statue is to reduce instances of fraud by providers and suppliers, enabling CMS to more closely observe these processes and also address waste and abuse. Only new HHAs are the focus here for CMS of enhanced oversight authority for enhanced monitoring and potential corrective actions in regard to RAPS.