This week in Medicare—3/6/2024
Advisory Opinion 24-01
On February 26, the OIG published Advisory Opinion 24-01 regarding the use of a “preferred hospital” network as part of Medigap policy. The requestor was looking to see if insurance companies could contract with a preferred hospital network to provide discounts on the otherwise applicable Medicare inpatient deductibles for policyholders and, in turn, the insurance company would provide a premium credit of $100 off the next renewal premium to policyholders who use a network hospital for an inpatient stay. The requestor was seeking an opinion as to whether this arrangement would be grounds for the imposition of sanctions under the anti-kickback statute and beneficiary inducements civil monetary penalty.
The OIG ruled favorable for the requestor and said that while the proposed arrangements would generate prohibited remuneration under the antikickback statute and beneficiary inducements civil monetary penalty, the OIG would not impose administrative sanctions in this case because the arrangement would be unlikely to increase costs for federal healthcare programs, is unlikely to lead to inappropriate utilization of healthcare services, and would be unlikely to impact competition or patient choices.
Updates to Hospital and Hospital Health Care Complex Cost Report
On February 29, CMS published Provider Reimbursement Manual Transmittal 22 regarding updates to the Hospital and Hospital Health Care Complex cost report. Changes include updates related to rural emergency hospitals, intensive outpatient program regulations, revised instructions about graduate medical education, and more.
Effective date: Cost reporting periods beginning on or after October 1, 2023.
Updates to Federally Qualified Health Center (FQHC) Cost Report
On February 29, CMS published Provider Reimbursement Manual Transmittal 7 regarding updates to the FQHC cost report. Changes relate to regulatory updates for intensive outpatient program visits and the addition of marriage and family therapist and mental health counselors as eligible providers.
Effective date: Cost reporting periods ending on or after January 1, 2024.
Updates to Community Mental Health Center Cost Report
On February 29, CMS published Provider Reimbursement Transmittal 4 regarding updates to the Community Mental Health Center (CMHC) cost report. These changes apply to worksheets used for reporting intensive outpatient program services.
Effective date: Cost reporting periods ending on or after January 1, 2024.
Lessons Learned During the Pandemic Can Help Improve Care in Nursing Homes
On February 29, the OIG published a Report regarding how lessons learned during the COVID-19 pandemic can help improve care in nursing homes. This is the third and final report in a series of reviews on this topic, and it focuses on the experiences with staffing and infection control practices in nursing homes during the pandemic. The previous reports were published in June 2021 and January 2023. The OIG based this report on accounts from nursing home administrators, who highlighted monumental staffing challenges in terms of both losing a significant number of staff and difficulties hiring, training, and retaining new staff. The nursing homes also noted difficulties with costs for supplies and challenges in implementing effective infection control practices.
The OIG provided five recommendations for CMS:
- Implement and expand upon its policies and programs to strengthen the nursing home workforce
- Reassess nurse aide training and certification requirements
- Update the nursing home requirements for infection control to incorporate lessons learned from the pandemic
- Provide effective guidance and assistance to nursing homes on how to comply with updated infection control requirements
- Facilitate sharing of strategies and information to help nursing homes overcome challenges and improve care
CMS did not state its opinions on the OIG recommendations.
CMS Issues Final Guidance on New Medicare Prescription Payment Plan
On February 29, CMS published a Press Release to announce the release of Final Guidance on the new Medicare Prescription Payment Plan, a provision of the Inflation Reduction Act that will allow people with Medicare prescription drug coverage the option to pay out-of-pocket costs in monthly payments. The program will start in 2025, and the guidance is geared toward Part D plan sponsors and pharmacies. It addresses topics such as identifying Medicare Part D enrollees likely to benefit from the program, the opt-in process for Part D enrollees, program participant protections, and the data collection needed to evaluate the program.
CMS published a Fact Sheet on the guidance on the same date.
CMS Statement on Current Status of Blood Tests for Organ Transplant Rejection
On February 29, CMS updated a Statement regarding recent controversy over MAC billing guidance that was issued on March 31, 2023, and appeared to limit reimbursement for molecular testing for organ transplant rejection. In the updated statement, CMS noted that the MACs have since removed and replaced that billing article, and the new article restores a table of solid organ allograft rejection tests that meet coverage criteria. It also removes explanatory language that had caused confusion for physicians and patients as to whether these tests would be covered.
CMS reaffirmed in the statement that neither CMS nor the MACs are changing patient access to blood tests that monitor for organ transplantation rejection in medically appropriate circumstances. CMS’ previous statement on this issue was published in September 2023.
Patient Driven Payment Model (PDPM) Corrections to Interrupted Stay Edits
On March 1, CMS published One-Time Notification Transmittal 12525, which rescinds and replaces Transmittal 12286, dated October 5, 2023, to remove provider education BR 13360.3.
The original transmittal was issued to update claims processing edits for skilled nursing facility PDPM interrupted stay claims.
Effective date: April 1, 2024
Implementation date: April 1, 2024
Stay of Enrollment
On March 1, CMS published Medicare Program Integrity Transmittal 12524 regarding procedures for implementing the new “stay of enrollment” provider enrollment status. CMS established this status in the 2024 Physician Fee Schedule final rule.
CMS published MLN Matters 13449 on the same date to accompany the transmittal.
Effective date: April 1, 2024 - For Business Requirement 13449.6 and Section 10.4.9(D)(2) of Chapter 10.; 90 days from issuance - The MAC shall begin work on all other Business Requirements and provisions once this CR is placed on their contract but implement 90 days from issuance.
Implementation date: June 3, 2024 - The MAC shall begin work on all other Business Requirements and provisions once this CR is placed on their contract but implement 90 days from issuance.; 30 days from issuance - For Business Requirement 13449.6 and Section 10.4.9(D)(2) of Chapter 10.