This week in Medicare updates–1/18/2017
January 2017 Medicare Quarterly Provider Compliance Newsletter
CMS has released it’s latest Medicare Quarterly Provider Compliance Newsletter, which is designed to provide education on how to avoid common billing errors and other erroneous activities when dealing with the Medicare Fee-For-Service (FFS) Program. It includes guidance to help healthcare professionals address and avoid the top issues of the particular quarter. The First Quarter 2017 issue discusses the following:
- Comprehensive Error Rate Testing (CERT): Retinal photocoagulation
- CERT: Facet joint injection
- CERT: Radiation therapy
- OIG report: Stem cell transplants
- Recovery Auditor finding: Long-term acute care stays up to five days longer than the short-stay outlier (SSO) threshold
Modifications to the National Coordination of Benefits Agreement (COBA) Crossover Process
On January 6, CMS published Transmittal 1770, which rescinds and replaces Transmittal 1733, dated October 27, 2016, to modify the example Types of Bills (TOB) listing included in the last paragraph of the Policy section and in requirement 9681.3 to remove TOB 82x. CMS also revised the related MLN Matters article 9681 accordingly.
Effective date: April 1, 2017
Implementation date: April 3, 2017
Conditions of Participation for Home Health Agencies
On January 9, CMS published a Press Release regarding its finalized Conditions of Participation (CoP) governing home health agencies. The Conditions of Participation for Home Health Agencies Final Rule was published in the January 13 Federal Register. The Medicare and Medicaid CoP are the minimum health and safety standards a home health agency must meet to participate in the Medicare and Medicaid programs.
Medicare Compliance Review of NorthShore University HealthSystem for 2013 and 2014
On January 9, the OIG published a Report regarding NorthShore University HealthSystem which did not fully comply with Medicare billing requirements for 93 of the 190 claims reviewed, resulting in overpayments of $625,000 for CYs 2013 and 2014. The OIG estimates that the hospital received overpayments totaling at least $4.1 million for the audit period.
New Corporate Integrity Agreement Announced
On January 9, the OIG released information regarding a Corporate Integrity Agreement with MB2 Dental Solutions, LLC, Trung Tang, DDS, Chris Villanueva, DDS, Mauricio Dardano, DDS, Gabriel Shahwan, DDS, and Akhil Reddy, DDS, of Carrollton, TX.
Announcement of the Extension of Temporary Moratoria on Enrollment of Part B Non-Emergency Ground Ambulance Suppliers and Home Health Agencies in Designated Geographic Locations
On January 9, CMS published information in the Federal Register regarding the extension of statewide temporary moratoria on the enrollment of new Medicare Part B non-emergency ground ambulance providers and suppliers and Medicare home health agencies, subunits, and branch locations in Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey, as applicable, to prevent and combat fraud, waste, and abuse.
Comment Request: Community Mental Health Center Cost Report
On January 10, CMS posted a Comment Request in the Federal Register regarding Community Mental Health Center Cost Report. Form CMS–2088–17 cost report is needed to determine a provider’s reasonable costs incurred in furnishing medical services to Medicare beneficiaries and reimbursement due to or due from a provider. The primary function of the cost report is to collect data that is used by CMS to support program operations, payment refinement activities, and to make Medicare Trust Fund projections.
Revisions to the Office of Inspector General’s Exclusion Authorities Final Rule
On January 11, the OIG published a Final Rule in the Federal Register that amends regulations relating to exclusion authorities under the authority of the OIG. The final rule incorporates statutory changes, early reinstatement provisions, and policy changes, as well as clarifies existing regulatory provisions.
Effective date: February 13, 2017
Special Payment Provisions and Requirements for Qualified Practitioners and Qualified Suppliers of Prosthetics and Custom Fabricated Orthotics
On January 11, CMS released a Fact Sheet regarding a new Proposed Rule published January 12 in the Federal Register that would implement statutory requirements and specify:
- Qualifications needed for practitioners to furnish and fabricate prosthetics and custom-fabricated orthotics and for suppliers to fabricate prosthetics and custom-fabricated orthotics
- Accreditation requirements that qualified suppliers must meet in order to bill for prosthetics and custom‑fabricated orthotics
- Requirements that an organization must meet to accredit qualified suppliers to bill for prosthetics and custom-fabricated orthotics
- The time frame qualified practitioners and qualified suppliers must meet regarding applicable licensure, certification, and accreditation requirements
This rule would also remove the exemption from quality standards and accreditation that is currently in place for certain practitioners and suppliers who furnish or fabricate prosthetics and custom‑fabricated orthotics. In addition, this rule also includes authority for CMS to revoke the Medicare enrollment of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) suppliers that submit claims for items that do not meet the requirements of the statute and this proposed rule.
Comment Request: Mandatory Insurer Reporting Requirements of Section 111 of the Medicare, Medicaid, and SCHIP Act of 2007
On January 11, CMS posted a Comment Request in the Federal Register regarding mandatory insurer reporting requirements of Section 111 of the Medicare, Medicaid, and SCHIP Act of 2007.
Both GHP and NGHP entities have had and continue to have the responsibility for determining when
they are primary to Medicare and to pay appropriately, even without the mandatory Section 111 process.
New Interest Rate for Medicare Overpayments and Underpayments: 2nd Quarter FY 2017
On January 11, CMS published Transmittal 280 regarding 42 CFR Section 405.378, which provides for the charging and payment of interest on overpayments and underpayments to Medicare providers. The Secretary of Treasury certifies an interest rate quarterly using the most comprehensive data available on consumer interest rates to determine the certified rate.
Effective date: January 19, 2017
Implementation date: January 19, 2017
Proposed Decision Memorandum: Hyperbaric Oxygen Therapy NCA
On January 12, CMS posted a proposed decision memo regarding the reconsideration request to remove the coverage exclusion of Continuous Diffusion of Oxygen Therapy (CDO) from NCD Manual 20.29, Section C. This section of the NCD (Topical Application of Oxygen) considers treatment known as CDO as the application of topical oxygen and nationally non-covers this treatment.
CMS is proposing that no NCD is appropriate at this time concerning the use of topical oxygen for the treatment of chronic wounds. CMS proposes to amend NCD 20.29 by removing Section C, Topical Application of Oxygen, and in newly created NCD 270.7, "Topical Oxygen for Chronic Non-Healing Wounds," Medicare coverage of topical oxygen for the treatment of chronic wounds will be determined by the local contractors.
Pennsylvania Rural Health Model
On January 12, CMS published a Press Release and Fact Sheet regarding a new model under which participating rural hospitals would be paid based on all-payer global budgets—a fixed amount that is set in advance for inpatient and outpatient hospital-based services, and paid monthly by Medicare fee-for-service and all other participating payers. Pennsylvania, through its Department of Health, will be a key partner in jointly administering this Model with CMS.
December 2016 Provider Self-Disclosure Settlements
On January 13, the OIG released information on several December 2016 Provider Self-Disclosure Settlements, including:
- New LifeCare Hospitals of Northern Nevada, LLC d/b/a Tahoe Pacific Hospitals, of Nevada, which agreed to pay $57,425.51 for allegedly violating the Civil Monetary Penalties Law.
- KaleidAScope, Inc., of Pennsylvania, which agreed to pay $18,468.30 for allegedly violating the Civil Monetary Penalties Law. OIG alleged that KaleidAScope submitted claims for individual/intake therapy sessions that were billed as four units of service in 15-minute increments, instead of one unit of service.
- Wexner Heritage Village of Ohio, which agreed to pay $10,000 for allegedly violating the Civil Monetary Penalties Law.
- Dr. Henry Tripp, Oldtown Immediate Care, PA d/b/a Old Town Immediate and Family Care and Ameri-Care Family Practice, PA, of North Carolina, which agreed to pay $133,880.50 for allegedly violating the Civil Monetary Penalties Law. OIG alleged that Dr. Tripp submitted claims to Medicare for nurse practitioner services as though Dr. Tripp personally performed the services.
- Alternative Consulting Enterprises, Inc., of Pennsylvania, which agreed to pay $126,102.38 for allegedly violating the Civil Monetary Penalties Law.
- The City of Grand Junction, Colorado, which agreed to pay $25,288.28 for allegedly violating the Civil Monetary Penalties Law. OIG alleged that Grand Junction staffed its ambulance transport services with two individuals whose Emergency Medical Technician (EMT) Basic or EMT Paramedic certifications were expired.
Affordable Care Act Bundled Payments for Care Improvement Initiative - Recurring File Updates Models 2 and 4 April 2017 Updates
On January 13, CMS published Transmittal 166 to update the participating hospital files, episodes, and prospective bundled payment amounts associated with the Bundled Payments for Care Improvement initiative, Model 2 and Model 4.
Effective date: April 1, 2017
Implementation date: April 3, 2017
April 2017 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
On January 13, CMS published Transmittal 3692 and MLN Matters 9945 regarding the April 2017 quarterly update. Medicare will use these files to determine the payment limit for claims for separately payable Medicare Part B drugs processed or reprocessed on or after April 3, 2017, with dates of service April 1, 2017, through June 30, 2017.
Effective date: April 1, 2017
Implementation date: April 3, 2017
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for April 2017
On January 13, CMS published Transmittal 3691 regarding the changes that included in the April 2017 quarterly release of the edit module for clinical diagnostic laboratory services.
Effective date: October 1, 2016
Implementation date: April 3, 2017