This week in Medicare—10/18/2023
Medicare Preventive Services
On October 10, CMS updated its Medicare Preventive Services website to add in code updates for Hepatitis B, mammography, and prostate cancer.
Medicare Provider Compliance Tips
On October 10, CMS updated its Medicare Provider Compliance Tips website with a wide range of revisions. This included new information for ambulatory surgical centers, E/M services, hip and knee replacements, pneumatic compression devices, and respiratory assist devices. It also added documentation requirements/examples for a variety of service areas.
Final Rule: Medicare Secondary Payer and Certain Civil Money Penalties
On October 11, CMS published a Final Rule in the Federal Register regarding how and when CMS must take action via civil monetary penalties when group and non-group health plans fail to meet Medicare Secondary Payer reporting obligations. The final rule also establishes CMP amounts and circumstances under which CMPs will and will not be imposed. This rule was initially proposed in February 2020.
Effective date: December 11, 2023
Applicability date: The provisions of this rule are applicable on or after October 11, 2024
Medicare Could Save Millions if It Implements an Expanded Hospital Transfer Payment Policy for Early Discharges to Post-Acute Care (PAC)
On October 11, the OIG published a Review of how the hospital transfer policy for discharges to PAC would financially affect Medicare and hospitals if CMS expanded the policy to include all Medicare Severity Diagnosis-Related Groups (MS-DRG). CMS has not made significant changes to the criteria for determining which MS-DRGs qualify for PAC transfer payments since 2005. For this review, the OIG looked at a stratified sample of 100 acute care inpatient hospital claims that were billed with specified MS-DRGs from 2017-2019 that were not subject to the hospital transfer policy for discharges to PAC. The OIG found that had the transfer payment policy been expanded to include these MS-DRGs, 99 of the 100 claims could have had transfer payments based on the reduced per diem rate and it would have resulted in net Medicare cost savings of $1 million. On the basis of the sample, the OIG estimates that Medicare could have saved approximately $694 million from 2017-2019 if it had expanded the hospital transfer policy to include all MS-DRGs.
The OIG recommends CMS conduct an analysis of its hospital transfer payment policy for discharges to PAC and expand the policy as necessary. CMS said it will examine the data relative to the current list of MS-DRGs that are subject to the policy to potentially assist in the identification of additional MS-DRGs for future rulemaking.
Notice of New Interest Rate for Medicare Overpayments and Underpayments – 1st Quarter FY 2024
On October 11, CMS published Medicare Financial Management Transmittal 12297 regarding the updated interest rate for Medicare overpayments and underpayments. The latest private consumer rate has been changed to 12.125%.
Effective date: October 17, 2023
Implementation date: October 17, 2023
Final Decision Memo: Percutaneous Transluminal Angioplasty (PTA) of the Carotid Artery Concurrent with Stenting
On October 11, CMS published a Final Decision Memo regarding the reconsideration of NCD 20.7 for PTA. CMS will cover PTA and carotid artery stenting (CAS) with embolic protection in patients with asymptomatic carotid artery stenosis ≥ 70% and in patients with symptomatic carotid artery stenosis ≥ 50%. This expands coverage to individuals who were previously only eligible under clinical trials, allows coverage for beneficiaries at standard surgical risk, and adds a formal shared decision-making interaction with the individual prior to the procedure. The final decision differs from the proposed decision memo by changing some of the imaging requirements and removing a proposal that would have eliminated facility standards. CMS is maintaining standards for facilities to perform CAS procedures but is removing a requirement for CMS to approve facilities.
Payments to Home Health Agencies That Do Not Submit Required Quality Data – This CR Rescinds and Fully Replaces CR 10874
On October 12, CMS published Medicare Quality Reporting Incentive Programs Transmittal 12293 regarding updates to language in the manual for the home health 2% payment reduction process. Changes include aligning language across pack settings for the CMS-designated data submission system and clarifying language for the number of survey-eligible patients related to filling out an exemption form for HHCAHPS.
Effective date: January 1, 2023
Implementation date: November 13, 2023
Omnibus CR to Implement Policy Updates in the CY 2023 Physician Fee Schedule (PFS) Final Rule
On October 12, CMS published Medicare Claims Processing Transmittal 12299, which rescinds and replaces Transmittal 11865, dated February 16, to provide clarifications on CMS policy and related claims processing instructions for colonoscopies within the context of a complete colorectal cancer screening. This includes revising the policy section with additional verbiage, adding BR 13017-04.5.3, and revising BRs 13017-04.1 and 13017-04.4 – 04.10. The change request was amended to remove the requirement that contractors shall return to provider/return as unprocessable certain screening colonoscopy claims that do not include the KX modifiers. While the original transmittal was issued alongside transmittals for the Benefit Policy Manual and National Coverage Determinations Manual, this transmittal does not make any revisions to those manuals. The original transmittal was issued regarding the implementation of changes from the 2023 PFS Final Rule.
CMS has yet to revise MLN Matters 13017 to accompany the updated transmittal.
Effective date: January 1, 2023
Implementation date: November 13, 2023 – For requirements subject to revision in amended CR only; February 27, 2023 - requirements implementation date; April 3, 2023 - for release tracking purposes only
2024 Medicare Parts A & B Premiums and Deductibles
On October 12, CMS published a Fact Sheet regarding the 2024 Medicare Parts A & B premiums, deductibles, and coinsurance amounts. The standard 2024 amounts are:
- Part A inpatient hospital deductible - $1,632
- Part A daily coinsurance (61st - 90th day) - $408
- Part A daily coinsurance (lifetime reserve days) - $816
- Part B monthly premium - $174.70
- Part B annual deductible - $240
- Skilled nursing facility coinsurance - $204
CMS Releases 2024 Medicare Advantage and Part D Star Ratings
On October 13, CMS published a Press Release regarding the star ratings for 2024 Medicare Advantage and Part D Prescription Drug Plans. Approximately 42% of Medicare Advantage plans offering prescription drug coverage in 2024 will have at least a four-star rating, down from 51% in 2023. The average star rating for all Medicare Advantage plans with prescription drug coverage is 4.04% for 2024, a decrease from the 2023 average of 4.14%.
CMS published a Fact Sheet on the star ratings on the same date.
OIG Advisory Opinion No. 23-07
On October 13, the OIG published an Advisory Opinion regarding a proposed arrangement where an employer proposed to pay a bonus to its employed physicians based on net profits derived from certain procedures performed by the physicians. The requestor, which operates ambulatory surgery centers, would provide bonus compensation to its physician employees who perform outpatient surgical procedures at either of the two ASCs in a given calendar quarter. The bonus compensation would consist of 30% of the requestor’s net profits from the ASC facility fee collections attributable to that physician’s procedures performed at the ASC for that quarter. The requestor was seeking an opinion as to whether this arrangement would constitute grounds for the imposition of sanctions under the exclusion authority or civil monetary penalty provisions related to the anti-kickback statute.
The OIG said this arrangement would not be grounds for the imposition of sanctions, as the arrangement would fall under a statutory exception and regulatory safe harbor for employees.
Final Decision Memo: Beta Amyloid Positron Emission Tomography (PET) in Dementia and Neurodegenerative Disease
On October 13, CMS published a Final Decision Memo regarding NCD 220.6.20. CMS is removing this NCD and will end coverage with evidence development (CED) for PET beta-amyloid imaging. It will instead have MACs determine coverage for this imaging.