Home health agencies are coming up on the final phase of PDGM. And while it may seem like one more administrative burden, this final update will likely be a welcome change for your agency. RAPs will be phased out, and home health agencies will revert to the one-claim-per-patient-per-month concept—known as the Notice of Admission (NOA). Do you fully understand how this transition will affect your billing and review processes?

By: Brandy Shifteh

In our recent webinar, Embracing PDGM’s final phase benefits of NOA, industry experts discussed lessons learned from No-Pay RAPs and what to expect with new notice of admission (NOA) regulations.

While we’ve learned that the No-Pay RAP process has resulted in penalties from late billing, costly effects from inefficient staffing, and time-consuming exception requests, the NOA implementation will come with its own set of compliance and regulation considerations.

Here, we’ll discuss six NOA submission requirements to consider for when it becomes effective on January 1, 2022. Some of this may sound familiar, as many of the policies mirror current No-Pay RAP regulations.

What is the admission period?

Essentially new language for a new requirement, the home health admission period is a claims processing concept used to correctly enforce primary home health agency assignments, and to trigger consolidated billing edits. CMS defines it as the period between the from date of an NOA and the discharge date.

An admission period can contain several 30-day periods of care and their corresponding claims up until the point that the patient is discharged. If the patient were then to be readmitted, a new NOA would be required within five days of that new start of care.

Understanding NOA submissions

While home health agencies will no longer be required to submit No-Pay RAPs for any period of care with a from date on or after January 1, 2022, they will instead notify Medicare systems via submission of an NOA for each admission. This NOA must be submitted within five calendar days of the admission, just as the current No-Pay RAP requirement.

Submitted using bill 32A, the NOA opens the first period of care and establishes the primary home health agency and triggers consolidated billing edits. Bill 329 can then be used for claims for periods of care following the submission of your initial NOA.

Non-timely submission reduction in payment

If an NOA submission is late—not submitted within five calendar days from start of care—agencies will be penalized with a 1/30 reduction to the wage-adjusted 30-day period payment amount for each day from the start of care until the NOA submission date.

Just as with No-Pay RAP penalties, this payment reduction can be significant. If you submit the NOA on day six, that will equate to a 20% payment reduction, which continues to increase with each late day. Keep in mind that the start of care date is considered day zero, and payment reductions are the provider’s liability.

Exceptional circumstances

There are exceptions that can waive the consequences of late filings, but the home health agency must provide sufficient information in the remarks section of their claim to allow the MACs to research the case. If these remarks are not sufficient, the MAC will request additional documentation, which is why it is crucial to keep documents that support evidence of timely submission—including screen images, Medicare system screens, and relevant printouts.

CMS specifically calls out three circumstances for which the MACs will not grant exception to
the payment reduction:

  • If the agency can correct the NOA without waiting for the Medicare system’s actions
  • If the agency submits a partial or incomplete NOA to fulfill the timely requirement
  • If the agency with multiple provider identifiers submits the identifier of a location that did not provide the service

CMS has clarified that a partial NOA would be a submission that is missing required fields or has invalid values in those fields.

Medicare secondary payers and changes to original Medicare

If the patient has an MSP identified at the start of care, the NOA should be submitted, regardless of whether the MSP is primary or not. When a patient’s payer changes to original Medicare, a new start of care OASIS must be completed that reflects the date of the beneficiary’s change to original Medicare.

While this is not a new requirement, it’s important to remember that the five-day submission requirement does apply for payer changes to original Medicare. However, it you had no way to know due to circumstances out of your control, an exception should be requested.

Medicare Advantage payers

Billing and documentation requirements vary by MA plan, so home health agencies need to reach out to their contracted MA plans and start validating what those billing and documentation requirements will be in 2022. Moving forward, we recommend validating contracted MA plans annually as part of your contract review process, and validating billing requirements as a best practice at the point of intake.

Navigating the unknown

As the industry continues to analyze the current manual instructions for submitting the NOA, gaps and questions are being identified that require clarification and guidance from CMS. Soon in 2021, expect to see an additional “gap filler transmittal” that will provide further guidance, particularly as it relates to transfer and discharge scenarios causing confusion in the current state of No-Pay RAP.

Schedule a meeting with our experts to learn more about the HEALTHCAREfirst’s full service approach to revenue cycle management, CAHPS, and advanced analytics solutions for home health and hospice agencies nationwide. 

Brandy Shifteh

Brandy Shifteh is a Regulations Compliance Manager for MatrixCare and HEALTHCAREfirst (ResMed companies), where she is responsible for the monitoring and analysis of regulatory requirements to support product and service development.

Brandy is a registered nurse with over 25 years of operations management and consultant experience in the home health, hospice and private duty home care sector, with extensive experience in regulatory compliance, clinical/quality improvement programming and accreditation/survey preparedness. She is very
plugged in to the regulatory community, with relationships at both the state and federal level, and serves as an active member on several industry and national association advisory boards.

Brandy has also been very involved in the development of clinical analytics that support scrubbing of home health OASIS assessment data, clinical assessment reviews, diagnoses coding, and case mix/HIPPS scoring.