This week in Medicare updates–11/9/2016
CMS Updates to Policies and Payment Rates for End-Stage Renal Disease Prospective Payment System
On October 28, CMS released a final rule and Fact Sheet regarding the End-Stage Renal Disease (ESRD) final rule prospective payment system (PPS), which updates payment policies and rates for renal dialysis services furnished to beneficiaries on or after January 1, 2017. This rule also finalizes new quality measures to improve the quality of care by dialysis facilities treating patients with ESRD.
January 2017 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
On October 28, CMS posted Transmittal 3640 and MLN Matters 9843 regarding revisions to prior quarterly pricing files. CMS supplies contractors with the ASP and not otherwise classified (NOC) drug pricing files for Medicare Part B drugs on a quarterly basis. Medicare will use these files for claims for separately payable Medicare Part B drugs processed or reprocessed on or after January 3, 2017 with dates of service January 1, 2017, through March 31, 2017.
Effective date: January 1, 2017
Implementation date: January 3, 2017
New Physician Specialty Code for Hospitalist
On October 28, CMS posted Transmittal 3637, Transmittal 274, and MLN Matters 9716, establishing C6 as the new physician specialty code for Hospitalists. The Medicare physician specialty codes to describe unique types of physicians and others practice for programmatic and claims processing purposes.
The C6 code will also be valid for the following edits:
- Ordering/certifying Part B clinical laboratory and imaging, durable medical equipment (DME), and Part A home health agency (HHA) claims
- Critical Access Hospital (CAH) Method II Attending and Rendering claims
- Attending, operating, or other physician or nonphysician practitioner listed on CAH claims
Effective date: April 1, 2017
Implementation date: April 3, 2017
Instructions to Process Services Not Authorized by the Veterans Administration (VA) in a Non-VA Facility Reported With Value Code (VC) 42
On October 28, CMS posted Transmittal 3635 and MLN Matters 9818 to correct a misinterpretation of the changes in the May 3, 2013, Transmittal 1213, “Updating the Shared Systems and Common Working File to no Longer Create Veteran Affairs ‘I’ records in the Medicare Secondary Payer (MSP) Auxiliary File.” Transmittal 3635 clarifies how Medicare contractors process inpatient claims for services in a Non-VA facility that were not authorized by the VA.
Effective date: October 1, 2013
Implementation date: April 3, 2017
Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals, etc.; Correction
On October 31, CMS published a correction to the Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2017 Rates; Quality Reporting Requirements for Specific Providers; Graduate Medical Education; Hospital Notification Procedures Applicable to Beneficiaries Receiving Observation Services; Technical Changes Relating to Costs to Organizations and Medicare Cost Reports; Finalization of Interim Final Rules With Comment Period on LTCH PPS Payments for Severe Wounds, Modifications of Limitations on Redesignation by the Medicare Geographic Classification Review Board, and Extensions of Payments to MDHs and Low-Volume Hospitals final rule in the Federal Register. The notice corrects multiple typographical errors in the original rule.
Health Insurance Enforcement and Consumer Protections Cycle I Grant Awards
On October 31, CMS released a Fact Sheet describing the award of approximately $25.5 million in grants to 22 states and the District of Columbia to use for enforcement and oversight of issuer compliance with select Affordable Care Act key consumer protections.
Date Change & Phased Enforcement of Part D Prescriber Enrollment
On October 31, CMS released a Fact Sheet regarding the new phased enforcement approach and deadline for Part D prescriber enrollment requirements. Full enforcement has been moved from February 1, 2017, to January 1, 2019.
Final Payment Changes for Medicare Home Health Agencies Final Rule
On October 31, CMS released a final rule and accompanying Fact Sheet regarding the final changes made to the Medicare home health prospective payment system (HH PPS) for calendar year (CY) 2017. CMS estimates that Medicare payments to home health agencies would be reduced by 0.7% ($130 million) in 2017 based on changes in the final rule, including:
- A 2.5% home health payment update percentage
- Rebasing adjustments to the national, standardized 60-day episode payment rate, the national per-visit payment rates, and the non-routine medical supplies conversion factor
- The -0.97% adjustment to the national, standardized 60-day episode payment rate to account for nominal case-mix growth
Comment request: Annual Early and Periodic Screening, Diagnostic and Treatment Participation Report; Home and Community Based Services Waiver; Bid Pricing Tool for Medicare Advantage and Prescription Drug Plans; etc.
On October 31, CMS published a comment request in the Federal Register to gather information for multiple programs, reports, etc., including:
- Annual Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Participation Report
- Home and Community Based Services (HCBS) Waiver
- Bid Pricing Tool (BPT) for Medicare Advantage (MA) Plans and Prescription Drug Plans (PDP)
- Medication Therapy Management Program Improvements
Comment request: Waiver Application for Providers and Suppliers Subject to an Enrollment Moratorium
On October 31, CMS published a comment request in the Federal Register regarding a demonstration that, in conjunction with an expansion of the existing provider enrollment moratoria, will allow CMS to mitigate known vulnerabilities within the existing moratoria and will lead to increased investigations of fraud.
Comment request: Evaluation of the CMS Quality Improvement Organizations: Reducing Healthcare-Acquired Conditions in Nursing Homes; Provider Cost Report Reimbursement Questionnaire; Medicare Participation Agreement for Physicians and Suppliers; Indirect Medical Education and Supporting Regulations; Medicare Program/Home Health Prospective Payment System Rate Update for Calendar Year 2010: Physician Narrative Requirement and Supporting Regulation; and more
On October 31, CMS published a comment request in the Federal Register regarding multiple programs and initiatives, including:
- Evaluation of the CMS Quality Improvement Organizations: Reducing Healthcare-Acquired Conditions in Nursing Homes
- Provider Cost Report Reimbursement Questionnaire
- Medicare Participation Agreement for Physicians and Suppliers
- Indirect Medical Education and Supporting Regulations
- Financial Statement of Debtor
- Medicare Program/Home Health Prospective Payment System Rate Update for Calendar Year 2010: Physician Narrative Requirement and Supporting Regulation
- Patient’s Request for Medicare Payment
- Solicitation for Applications for Medicare Prescription Drug Plan 2018 Contracts
- Applications for Part C Medicare Advantage
Next round of Medicare Recovery Audit Contractors announced
On October 31, CMS announced that it has awarded the next round of Medicare Fee-for-Service Recovery Auditor contracts to:
- Region 1 – Performant Recovery, Inc.
- Regions 2 and 3 – Cotiviti, LLC
- Region 4 – HMS Federal Solutions
- Region 5 – Performant Recovery, Inc.
The Recovery Auditors in Regions 1-4 will perform postpayment review to identify and correct claims containing improper payments made under Medicare Part A and Part B. The Region 5 RAC will perform postpayment review of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) and Home Health/Hospice claims nationally.
Hospital Outpatient Prospective Payment Changes for 2017 final rule with comment period
On November 1, CMS posted the Calendar Year (CY) 2017 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System policy changes, quality provisions, and payment rates final rule with comment period.
CMS also issued an Interim Final Rule with comment period to establish Medicare Physician Fee Schedule (MPFS) rates for certain items and services furnished by certain off-campus provider-based departments to address changes required by Section 603 of the Bipartisan Budget Act of 2015.
With the final rule and interim final rule, CMS also released a related fact sheet and press release.
CMS Awards Contracts for the DMEPOS Competitive Bidding Program Round 1 2017
On November 1, CMS posted a Fact Sheet regarding the release of the Round 1 2017 contract suppliers for Medicare’s Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program.
CMS Hospital Value-Based Purchasing Program Results for Fiscal Year 2017
On November 1, CMS published a Fact Sheet regarding the results of the Hospital Value-Based Purchasing Program for 2017. The Fact Sheet also describes new and changing program requirements for FY 2018.
Medicare Diabetes Prevention Program (MDPP) Expanded Model
On November 2, CMS posted a Fact Sheet regarding the expansion of the the Medicare Diabetes Prevention Program (MDPP) expansion previously announced in early 2016. The 2017 Medicare Physician Fee Schedule final rule finalized the expansion. A related press release is also available.
2017 Medicare Physician Fee Schedule final rule
On November 2, 2016, CMS issued a final rule that updates payment policies and payment rates for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2017. CMS posted a related Fact Sheet regarding the final 2017 policy, payment, and quality provisions in the Medicare Physician Fee Schedule.
WPS Overpaid Medicare Disproportionate Share Hospital Payments
On November 2, the OIG published a report regarding the Wisconsin Physicians Service (WPS), which did not properly settle Medicare cost reports submitted by Indiana hospitals for Medicare disproportionate share hospital (DSH) payments in accordance with federal requirements. The 48 selected providers improperly claimed a total of 14,325 Medicaid patient days on their Medicare cost reports, resulting in DSH overpayments totaling $6.1 million.
New Corporate Integrity Agreements (CIA) announced
On November 2 and 3, the OIG reported five new CIAs, including CIAs with the following providers:
- Home Bound Healthcare, Inc. Home Bound Healthcare Hospice, Inc. Home Bound Healthcare Medical Equipment & Supplies, LLC Home Bound Healthcare Outpatient Therapy Services, LLC Home Bound Consulting, LLC Home Bound Healthcare Staffing, LLC
- Vibra Healthcare, LLC; Vibra Healthcare II, LLC; 8451 Pearl Street Operating Company, LLC D/B/A Vibra Hospital fo Denver; Vibra Hospital of San Diego, LLC; Vibra of Southeastern Michigan, LlC; Vibra Specialty Hospital of Dallas, LLC; Vibra Specialty Hospital of Portland, LLC; and 1300 Campbell Lane Operating Company, LLC D/B/A Southern Kentucky Rehabilitation Hospital
- U.S. Healthcare Supply, LLC; Spectrum Diabetic Services, LLC; Heritage Diabetic Supply, Inc.; Dependable Diabetic Supply, LLC; U.S. Diagnostics, Inc.; U.S. Diagnostics NJ; Edward J. Letko; and Jon P. Letko
CY 2017 Home Health Prospective Payment System (HH PPS) Rate Update; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements
On November 3, CMS posted the CY 2017 HH PPS Rate Update; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements final rule in the Federal Register. This final rule updates HH PPS payment rates, implements the last year of the 4-year phase-in of the rebasing adjustments to the HH PPS payment rates, updates case-mix weights using the most current data available, implements the 2nd-year of a 3-year phase-in of a reduction to the standardized 60-day episode payment, and finalizes changes to the methodology used to calculate payments made for high-cost outlier episodes of care. It also implements changes in payment for Negative Pressure Wound Therapy using a disposable device for patients under a home health plan of care, finalizes changes to the Home Health Value-Based Purchasing (HHVBP) Model and Home Health Quality Reporting Program (HH QRP), and more.
Therapy Cap Values for Calendar Year (CY) 2017
On November 4, CMS posted Transmittal 3644 with updated outpatient therapy caps of $1980 for CY 2017. Information related to this Recurring Update Notification can be found in Pub. 100-04 Chapter 5, Section 10.
Effective date: January 1, 2017
Implementation date: January 3, 2017
Oncology Care Model (OCM) Monthly Enhanced Oncology Services (MEOS) Payment Rate for Certain Non-Physician Practitioners (NPP)
On November 4, CMS posted Transmittal 162 to remove the payment adjustment for certain NPPs for the OCM MEOS Payment (G9678) so the NPPs receive the same payment rate as physicians for these services.
Effective date: April 1, 2017
Implementation date: April 3, 2017
Quarterly Update to the NCCI Edits
On November 4, CMS posted Transmittal 3646, which contains the normal update to the National Correct Coding Initiative (NCCI) procedure-to-procedure edits (PTP). The Recurring Update Notification applies to Pub. 100-04, Chapter 23, Section 20.9.
Effective date: January 1, 2017
Implementation date: January 3, 2017
Issuing Compliance Letters to Specific Providers and Suppliers Regarding Inappropriate Billing of Qualified Medicare Beneficiaries (QMB) for Medicare Cost-Sharing
On November 4, CMS posted Transmittal 1747 and MLN Matters 9817 to instruct Medicare Administrative Contractors (MAC) to issue a compliance letter instructing named providers and suppliers to refund any erroneous charges and recall any past or existing billing with regard to improper QMB billing.
Effective date: December 6, 2016
Implementation date: March 8, 2017
Implementation of Changes in the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for Calendar Year (CY) 2017
On November 4, CMS posted Transmittal 229 and MLN Matters 9807 regarding the implementation of CY 2017 rate updates for the ESRD PPS and payment for renal dialysis services furnished to beneficiaries with AKI in ESRD facilities. This recurring update notification applies to Pub. 100-02, Medicare Benefit Policy Manual, chapter 11, section 50.
The ESRD PPS, Coverage and Payment for Renal Dialysis Services Furnished to Individuals With AKI, ESRD Quality Incentive Program, DMEPOS Competitive Bidding Program Bid Surety Bonds, State Licensure and Appeals Process for Breach of Contract Actions, DMEPOS Competitive Bidding Program and Fee Schedule Adjustments, Access to Care Issues for DME; and the Comprehensive ESRD Care Model final rule was published in the Federal Register November 4.
Effective date: January 1, 2017
Implementation date: January 3, 2017
Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models
On November 4, CMS released the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models final rule in the Federal Register.
2016 Hospital Appeals Settlement Update
On November 4, CMS updated its Hospital Inpatient Reviews website to alert providers to an upcoming November 16 MLN Connects National Provider Call on the 2016 Hospital Appeals Settlement. CMS also states that the website will not be updated further regarding the 2016 process, but that details of the settlement process will be available at go.cms.gov/HASP2016, on the Hospital Appeals Settlement Process 2016 website.
Fiscal Year (FY) 2015 Minimum Data Set (MDS) Focused Survey Summary
On November 4, CMS published results from the FY 2015 MDS Focused Surveys. The survey summary describes the relevant background and the types of deficiencies and errors identified and provides technical resources for providers to help improve accuracy and help providers maintain compliance to enhance the safety and quality of care nursing home residents receive.