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CMS Implements Enhanced Oversight of New Home Health Agencies

Payment Matters

CMS recently announced through an MLN Matters article that it intended to place new home health agencies (HHAs) under enhanced oversight for a provisional period. The authority for CMS's oversight flows from a provision in the Affordable Care Act (ACA) that authorizes the Secretary of Health and Human Services (Secretary) to establish procedures for a provisional period of not less than 30 days but not more than one year, during which new providers or suppliers identified by the Secretary will be subject to "enhanced oversight, such as prepayment review and payment caps." ACA § 6403(a)(3), 42 U.S.C. § 1395cc(j)(3).

CMS has asserted that the purpose of the oversight is to help CMS closely monitor providers and supplier types that it has determined have a high risk of fraud, waste and abuse. CMS has determined that it will invoke the new oversight provisions to monitor new HHAs in all states and territories.

During Oversight

During the period of enhanced oversight, new HHAs will not receive the upfront payments prior to the provision of services that flow from HHAs' filing of Requests for Anticipated Payments (RAPs). However, HHAs must still file a RAP for each home health episode in order for the final claim to be processed and paid. Suppression of the RAP payment will not affect the final payment by Medicare for the HHA episode of care.

CMS notes in the MLN Matters that this provisional period of enhanced oversight, during which no RAP payments will be made, is unrelated to the Medicare final rule published November 13, 2018, that eliminated RAP payment for newly enrolled HHAs (those certified to participate in Medicare on or after January 1, 2019) beginning January 1, 2020. See 83 Fed. Reg. 56406 (Nov. 13, 2018).

Timing of the Oversight

CMS announced that it would begin placing new HHAs in enhanced oversight as early as February 15, 2019. The provisional period of oversight will be for a period not less than 30 days and not more than one year.

Notice to New HHAs

CMS or one of its contractors will mail correspondence to new HHAs being placed in a provisional period of enhanced oversight. The correspondence will be mailed to the record on file for the HHA and will include the following:

  • The beginning and end date for the provisional period of oversight;
  • Notice that RAP payments will be suppressed during this period; and
  • Notice that HHAs must still submit a RAP for each home health episode in order for the final claim to be processed.

For additional information on payment issues related to home health services, contact the author, Leslie Demaree Goldsmith, or any member of Baker Donelson's Reimbursement Team.

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