A few years ago PGBA began a review of agencies that had a level of 100 or more Request for Anticipated Payment (RAP) Take-backs in one calendar quarter. They sent agencies that fell into that category, a letter stating that they must file a corrective action plan and that RAP payments were suspended until PGBA determined that the situation had improved. PGBA treated everyone the exact same. So if you were an agency that typically files 800 RAPs per month or an agency that files 100 RAPs per month and you had 100 RAP take-backs in a calendar quarter you were on the list. So 4% vs 33% were treated the same. State and national associations got involved and convince PGBA authorities that they had to come up with a different strategy due to the fact that just using a number of take-backs was totally not equal for all providers. So, once PGBA approved the corrective action plans for the initial agencies they began paying RAPs again.
The review has continued. Currently, each quarter PGBA sends letters to agencies that have 25%+ take-backs in one calendar quarter a warning letter that states your denial percentage is elevated and that you are on the radar. The following quarter you typically receive the same letter if your percentage is still elevated. The third quarter you will receive the letter that requires a corrective action plan and your RAP payments will cease until PGBA see improvement in the percentage of take-backs.
