This week in Medicare updates–09/13/17
Revision to Publication 100-06, Chapter 3, Medicare Overpayment Manual, Section 200, Limitation on Recoupment
On September 1, CMS published MLN Matters 9815 to supplement CMS Medicare Financial Management Transmittal 292, a transmittal which updates the Medicare Overpayment Manual, section 200-200.2.1, Limitation on Recoupment, which was published the same day.
Effective date: April 2, 2018
Implementation dates: April 2, 2018
Clarification of the Billing of Immunosuppressive Drugs
On September 1, CMS published MLN Matters 10235 to supplement CMS Medicare Claims Processing Transmittal 3856, which updates the manual to remove a double negative statement in order to provide clear instruction on the billing of immunosuppressive drugs. The transmittal was also published September 1.
Effective date: October 2, 2017
Implementation dates: October 2, 2017
Internet Only Manual (IOM) Update to Pub. 100-04, Chapter 15 - Ambulance, to Restore Multiple Patients on One Trip Instructions
On September 1, CMS published MLN Matters 10245 to supplement CMS Medicare Claims Processing Transmittal 3855, which restores the "Multiple Patients on One Trip" instructions to Pub. 100-04, Chapter 15 - Ambulance, Section 30.1.2. The transmittal was also published September 1.
Effective date: October 2, 2017
Implementation dates: October 2, 2017
Recognition of Revised NAIC Model Standards for Regulations of Medicare Supplemental Insurance
On September 1, CMS published a notice in the Federal Register announcing the changes made by the Medicare Access and CHIP Reauthorization of 2015 (MACRA) to section 1882 of the Social Security Act, which governs
Medicare supplemental insurance. The notice also recognizes that the Model Regulation adopted by the National Association of Insurance Commissioners (NAIC) on August 29, 2016.
Areas outlined in this notice include legislative changes affecting Medigap Policies and Clarification and Standardized Benefit Packages.
Amendments made by section 401 of MACRA apply to issuers of Medigap policies for policies issued on or after January 1, 2020.
CMS Approves Texas CHIP Provisions to Assist with Hurricane Harvey Disaster Relief
On September 1, CMS issued a Press Release stating that CMS has expedited and approved disaster relief provisions for children eligible for the Children’s Health Insurance Program (CHIP) allowing Texas officials to adjust enrollment, redetermination policies, and cost sharing requirements for families living in or evacuated from areas impacted by Hurricane Harvey. The CHIP emergency effort gives the state the ability to take the following actions for enrollees in FEMA-declared disaster counties in Texas:
- Provide enrollees extended eligibility, allowing them to receive coverage beyond their renewal period.
- Streamline their application and renewal processes by waiving certain verification requirements and allowing self-attestation.
- Waive co-payments for children’s health care services.
- Waive the enrollment fee, a required payment for health coverage.
CMS Assists Texas and Louisiana with Hurricane Harvey Recovery
On September 2, CMS issued a Press Release stating that CMS is responding to the damage left by Hurricane Harvey by assisting Medicare and Medicaid beneficiaries, providers, facilities, and the general public by ensuring access to healthcare services and resources are not interrupted during this time. Additionally, CMS has put in place flexibilities, including:
- Delay or suspend onsite annual re-certification and revisit surveys for certified providers.
- Delay or suspend certain enforcement actions.
- Allow additional time for providers to submit Plans of Corrections.
- Allow healthcare providers to exceed their certified bed capacity by 10 percent (additional increases over the 10 percent will be processed on a case by case basis to assure safety).
- Allow clinical labs to set up Temporary Testing Sites and perform waived testing following the manufacturer’s instructions at the temporary site.
On September 7, CMS issued another Press Release stating that it is waiving provider screening requirements in Texas and Louisiana during hurricane recovery efforts, and on September 8, CMS announced that it will be providing guidance and support to people impacted by the loss of durable medical equipment and supplies due to the hurricane.
October 2017 Update of the Ambulatory Surgical Center (ASC) Payment System
On September 5, CMS published MLN Matters 10259 to supplement CMS Medicare Claims Processing Transmittal 3854, published September 1. The transmittal updates the ASC payment system and specifies payment rates for separately payable drugs and biologicals, including descriptors for newly created Level II Healthcare Common Procedure Coding System (HCPCS) codes for drugs and biologicals (ASC DRUG files), the ASC PI file, the calendar year (CY) 2017 ASC payment rates for covered surgical and ancillary services (ASCFS file), and an ASC Code Pair file, if applicable.
This MLN Matters further explores these changes.
Effective date: October 2, 2017
Implementation dates: October 2, 2017
Information Collection Request: Medicare Health Outcomes Survey (MHOS) & Appeals of Quality Bonus Payment Determinations
On September 5, CMS published a Notice in the Federal Register around information collections for the upcoming MHOS and appeals of quality bonus payment determinations.
Comments are due by October 5, 2017.
Updated Information Collections: Clinical Laboratory Improvement Amendments of 1988 (CLIA) Budget Workload and PACE Organization Application Process
On September 5, CMS published a Notice in the Federal Register around a proposed extension without change of an ongoing information collection regarding CLIA and a revision of a current collection regarding the PACE application process.
Comments are due by November 6, 2017.
Calculation of Potential Inflation-Indexed Rebates for Medicare Part B Drugs 2017
On September 5, the OIG posted findings of a study around the potential inflation-indexed rebates for Medicare Part B drugs for 2017.
The study found that while inflation indexed rebates are intended to help protect State Medicaid programs and the Federal Government from significant drug price increases, Medicare Part B does not have similar rebate authority.
This analysis did not take into account how implementation of a Part B rebate requirement could affect beneficiary coinsurance obligations, beneficiary access to prescription drugs, and the overall pharmaceutical marketplace. Furthermore, we did not address the operational burden of implementing such a requirement.
Impact of Price Substitutions Based on 2014 Average Sales Prices on Medicare Part B Drug Payments
On September 5, the OIG posted findings of a study around the the impact of price substitutions based on 2014 average sales prices on Medicare Part B drugs. The study found:
- CMS lowered Part B reimbursement for 14 drugs on the basis of data from 2014.
- CMS's price-substitution policy saved Medicare and its beneficiaries $24 million over 1 year based on 2014 data.
- Medicare and its beneficiaries could have saved up to an additional $9 million over 1 year by expanding the price-substitution criteria to include drugs that exceeded the 5% threshold in a single quarter.
Based on these findings, OIG recommends that CMS expand the price-substitution policy. CMS did not concur.
Memorandum: Revisions to State Operations Manual (SOM) Hospital Appendix A
On September 6, CMS issued a memorandum to state survey agency directors clarifying guidance under Appendix A of the SOM to address the following:
- The Social Security Act, Section 1861(e) defines the statutory definition of a hospital
- A hospital is primarily engaged in providing inpatient services under section 1861(e)(1) of the Act when it is directly providing services to inpatients
- In order to qualify for a provider agreement as a hospital under Medicare and Medicaid, an entity must meet and continue to meet all of the statutory provisions of §1861(e) of the Act, including the Condition of Participation (CoP) requirements, which do not apply to Psychiatric Hospitals or Critical Access Hospitals (CAH)
- A hospital must have inpatients at the time of survey in order for surveyors to directly observe the actual provision of care and services to patients, and the effects of that care
- The use of benchmarks for average daily census (ADC) and average length of stay (ALOS) data for the hospital will be two factors, in addition to other factors, utilized to determine if the hospital is primarily engaged
New Corporate Integrity Agreements
On September 7, the OIG published information on a new Corporate Integrity Agreements with the following organizations:
- Critz, Frank A., M.D, of Radiotherapy Clinics of Georgia, LLC; Physician Oncology Services Management Company, LLC; RCOG Cancer Centers LLC, of Atlanta, GA
- Deshmukh, Yusuf K., M.D.; Elizabethtown Hematology and Oncology, PLC, of Elizabethtown, KY
- Roanoke Valley Rescue Squad, Inc., of Roanoke Rapids, NC
- NextCare Holdings, Inc., of Mesa, AZ
- Spillers, Steven, M.D., of Colorado Springs, CO
OIG Advisory Opinion: Use of "Preferred Hospital" Networks as Part of Medicare Supplemental Health Insurance ("Medigap") Policies
On September 7, the OIG published an Advisory Opinion. A healthcare organization wrote the OIG requesting an advisory opinion regarding a retail pharmacy chain’s proposal to allow Federal health care program beneficiaries to participate in a paid membership program that includes discounts on certain prescriptions and clinic services. The OIG found that the proposed arrangement would not constitute grounds for the imposition of civil monetary penalties.
Updated List of Excluded Individuals and Entities (LEIE)
On September 7, the OIG updated its LEIE. Along with issuing a new downloadable database, OIG also offered a list of Exclusions, Reinstatements, a Monthly Supplemental Archive, and Profile Corrections.
OIG Reports Highlight Hospital Billing Issues
On September 7, CMS published MLN Matters SE17017, a Special Edition Article to address two significant issues in which hospitals are making coding errors on Medicare claims, improper use of Modifier -59 and incorrect procedure coding for mechanical ventilation.
October Quarterly Update for 2017 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule
On September 8, CMS published Medicare Claims Processing Transmittal 3859, the standard quarterly update for the DMEPOS. The DMEPOS fee schedule is updated on a quarterly basis, when necessary, to implement fee schedule amounts for new codes and correct any fee schedule amounts for existing codes. The quarterly update process for the DMEPOS fee schedule is located in Pub. 100-04, Medicare Claims Processing Manual, chapter 23, section 60.
Effective date: October 1, 2017
Implementation dates: October 2, 2017
2018 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update
On September 8, CMS published Medicare Claims Processing Transmittal 3857, which makes changes to HCPCS codes and Medicare Physician Fee Schedule designations and will be used to revise CWF edits to allow A/B MACs to make appropriate payments in accordance with policy for SNF CB in Chapter 6, Section 110.4.1 for A/B MACs (B) and Chapter 6, Section 20.6 for A/B MACs (A)
Effective date: January 1, 2018
Implementation dates: January 2, 2018
2018 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update
On September 8, CMS published Medicare Claims Processing Transmittal 3858, which makes changes to HCPCS codes and Medicare Physician Fee Schedule designations and will be used to revise CWF edits to allow A/B MACs to make appropriate payments in accordance with policy for SNF CB in Chapter 6, Section 110.4.1 for A/B MACs (B) and Chapter 6, Section 20.6 for A/B MACs (A)
Effective date: January 1, 2018
Implementation dates: January 2, 2018
Fiscal Year (FY) 2018 Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) PPS Changes
On September 8, CMS published Medicare Claims Processing Transmittal 3858, a recurring update of changes to IPPS and LTCH PPS for FY 2018. This year’s changes include:
- Changes to policy around IPPS and LTCH PPS Pricer Software, to be released October 1, which will include updated rates that are effective for claims with discharges occurring on or after October 1, 2017
- Medicare Severity-Diagnosis Release Group (MS-DRG) Grouper and Medicare Code Editor (MCE) Changes
- Post-acute Transfer and Special Payment Policy
- New Technology Add-On
- Cost of Living Adjustment (COLA) Update for IPPS PPS
- FY 2017 Wage Index Changes and Issues
Effective date: October 1, 2017
Implementation dates: October 2, 2017
Information Collection Extension and Comment Request: Standards Related to Reinsurance and Risk
On September 8, CMS published a Notice in the Federal Register that it intends to extend a current information collection regarding standards related to reinsurance, risk corridors, and risk adjustment. This information is to be used to revise, update, and remove obsolete programs.
Comments are due by November 7, 2017.