This week in Medicare updates–12/14/2016
Critical Access Hospital (CAH) Appendix W Revisions
On December 1, CMS published a Memorandum regarding updates to the Appendix W of the State Operations Manual (SOM). The CAH Emergency Services standard was revised in 2004 and 2006 but those revisions were not previously included in the SOM.
CMS Releases 2015 National Health Expenditures
On December 2, CMS published a Press Release regarding 2015 national health expenditures. In 2015, per-capita healthcare spending grew by 5% and overall health spending grew by 5.8%, according to a study by the CMS Office of the Actuary.
Visiting Nurse Service of New York Budgeted Costs That Were Not Appropriate and Claimed Some Unallowable Hurricane Sandy Disaster Relief Act Funds
On December 5, the OIG published a Report regarding the Visiting Nurse Service of New York, a not-for-profit home health care agency in New York, NY, which budgeted inappropriate costs and claimed some unallowable Hurricane Sandy Disaster Relief Act Funds.
Hospitals Did Not Always Comply With Medicare Requirements for Reporting Cochlear Devices Replaced Without Cost
On December 5, the OIG published a Report regarding compliance with Medicare requirements for reporting cochlear devices replaced without cost. To identify devices replaced without cost, CMS requires hospitals to report the modifier -FB and reduced charges (services furnished prior to January 1, 2014) or value code FD along with condition code 49 or 50 (services furnished on or after January 1, 2014). For 116 of the 149 claims the OIG reviewed, hospitals did not report the appropriate modifiers and charges (for claims with dates of service in calendar years (CY) 2012 and 2013) or a combination of the appropriate value code and condition codes (for claims with dates of service in CY 2014) to alert the Medicare contractors of the need for payment adjustments. Hospitals received $2.7 million in Medicare overpayments for those 116 incorrectly billed claims.
OIG Advisory Opinion No. 16-12
On December 5, the OIG published an Advisory Opinion regarding a laboratory’s proposal to provide services consisting of the labeling of test tubes and specimen collection containers at no cost to dialysis facilities. Based on the facts provided, the OIG concluded that the proposed arrangement could potentially generate prohibited remuneration under the Anti-Kickback Statute.
CY 2017 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
On December 5, CMS published Transmittal 3671 and MLN Matters 9854, which provide the CY 2017 annual update for the Medicare DMEPOS fee schedule. The instructions include information on the data files, update factors, and other information related to the update of the fee schedule.
Effective date: January 1, 2017
Implementation date: January 3, 2017
Changes to the End-Stage Renal Disease (ESRD) Facility Claim (Type of Bill 72X) to Accommodate Dialysis Furnished to Beneficiaries with Acute Kidney Injury (AKI)
On December 6, CMS published Transmittal 1759, which rescinds and replaces Transmittal 1725, dated October 13, 2016, to update the Provider Education Requirements.
Effective date: January 1, 2017
Implementation date: January 3, 2017
FY 2015 Medicare FFS RAC Report to Congress
On December 7, CMS posted the Fiscal Year 2015 Recovery Audit Program Report to Congress. CMS has also published the related FY 2015 Recovery Audit Program Appendices.
Revisions to the Safe Harbors Under the Anti-Kickback Statute and Civil Monetary Penalty Rules Regarding Beneficiary Inducements
On December 7, the OIG published a final rule in the Federal Register, amending the safe harbors to the anti-kickback statute by adding new safe harbors that protect certain payment practices and business arrangements from sanctions under the anti-kickback statute. This rule updates the existing safe harbor regulations and enhances flexibility for providers and others to engage in business arrangements to improve efficiency and access to quality care while protecting programs and patients from fraud and abuse.
Effective date: January 6, 2017
Revisions to the Office of Inspector General's Civil Monetary Penalty (CMP) Rules
On December 7, the OIG published a final rule in the Federal Register, amending its CMP rules to incorporate new CMP authorities, clarify existing authorities, and reorganize regulations on civil money penalties, assessments, and exclusions to improve readability and clarity.
Effective date: January 6, 2017
OIG Most-Wanted Fugitive Captured
On December 7, the OIG posted information on the capture of one of its most-wanted fugitives, Martinez Ruiz. In June 2016 Martinez was indicted on charges of healthcare fraud. Investigators believe that Martinez, through his home health company, Magnifique Home Health in Miami, Florida, was paid over $4.7 million for services it did not render.
New Corporate Integrity Agreement (CIA) Updates
On December 7, the OIG published information on five new CIAs completed in November with the following providers:
- Lee, Michael, DPM of Basin Foot and Ankle in Moses Lake, WA
- Lerner, Brian, MD, and Lerner, MD, PA, in Owings Mills, MD
- Select Medical Corporation in Mechanicsburg, PA
- Chaimowitz, Chaim, in Wesley Hills, NY
- Krentel, Rod, in Shreveport, LA
Policy Statement Regarding Gifts of Nominal Value To Medicare and Medicaid Beneficiaries
On December 7, the OIG published a Policy Statement on what it considers to be a gift of nominal value. The OIG is adjusting the previous amounts, now interpreting “nominal value” as having a retail value of no more than $15 per item or $75 in the aggregate per patient on an annual basis. As with its previous interpretation, the items may not be cash or cash equivalents.
Percutaneous Image-guided Lumbar Decompression for Lumbar Spinal Stenosis
On December 7, CMS published a Decision Memorandum regarding Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (CAG-00433R) National Coverage Determination (NCD). CMS is finalizing its proposal to continue Coverage with Evidence Development (CED) and expand the January 2014 NCD. CMS will cover through a prospective longitudinal study PILD procedures using an FDA-approved/cleared device that successfully completed a CMS-approved randomized controlled trial (RCT) that met the criteria listed in Section 150.13 of the NCD Manual.
Final Medicare Outpatient Observation Notice (MOON) (CMS-10611) Available
On December 8, CMS published a Fact Sheet regarding the release the final OMB-approved Medicare Outpatient Observation Notice (MOON) along with instructions for the form. Hospitals and critical access hospitals (CAH) must begin using the MOON no later than March 8, 2017. The Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) requires hospitals and CAHS to provide notification to individuals receiving observation services as outpatients for more than 24 hours explaining the status of the individual as an outpatient, not an inpatient, and the implications of that status.
Updated Provider Self-Disclosure Statement
On December 8, the OIG posted information on Antelope Valley Hospital of California, which agreed to pay $190,087.90 for allegedly violating the Civil Monetary Penalties Law. OIG alleged that the hospital employed an individual that it knew or should have known was excluded from participation in federal healthcare programs.
Beneficiary Engagement and Incentives Models: Shared Decision Making (SDM) Model
On December 8, CMS published a Fact Sheet regarding the SDM Model, which will test a specific approach to integrating a structured four-step shared-decision-making process into the clinical practice of practitioners who are participating Accountable Care Organizations. The shared-decision-making process is a collaboration between the beneficiary and the practitioner.
Beneficiary Engagement and Incentives Models: Direct Decision Support (DDS) Model
On December 8, CMS published a Fact Sheet regarding the DDS Model, which will test an approach to shared decision-making provided outside of the clinical delivery system by an organization that provides health management and decision support services. The Decision Support Organizations (DSO) will not interfere with the practitioner-patient relationship, but encourage it.
Clarification of Certification Statement Signature and Contact Person Requirements
On December 9, CMS published Transmittal 689 to provide clarification to the certification statement signature requirements for Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) and paper applications. In addition, this CR addresses contact person requirements.
Effective date: January 9, 2017
Implementation date: January 9, 2017
Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Updates
On December 9, CMS published Transmittal 230 regarding updates to the Medicare Benefit Policy, Chapter 13, to remove obsolete or duplicative material and to clarify payment and other policy information. This includes changes regarding the services furnished by auxiliary personnel incident to a transitional care management or chronic care management visit that may be furnished under general supervision, as finalized in the CY 2017 Physician Fee Schedule Final Rule. All other revisions serve to clarify existing policy and remove obsolete information.
Effective date: March 9, 2017
Implementation date: March 9, 2017
Comprehensive Care for Joint Replacement (CJR) Model: Skilled Nursing Facility (SNF) 3-Day Rule Waiver
On December 9, CMS published MedLearn Matters SE1626 to inform SNFs of the policies surrounding use of the 3-day stay waiver available for use under the CJR Model and to provide instructions on using the demonstration code 75 on applicable CJR claims submitted on or after January 1, 2017.
January 2017 Integrated Outpatient Code Editor (I/OCE) Specifications Version 18.0
On December 9, CMS published Transmittal 3674 to provide the I/OCE instructions and specifications used under the outpatient prospective payment system (OPPS) and Non-OPPS for hospital outpatient departments, community mental health centers, all non-OPPS providers, and for limited services when provided in a home health agency not under the Home Health Prospective Payment System or to a hospice patient for the treatment of a non-terminal illness.
Effective date: January 1, 2017
Implementation date: January 3, 2017
Zika Health Care Services Program
On December 9, CMS published a Notice in the Federal Register regarding the November 9, 2016 publication of a funding opportunity providing up to $66.1 million available to support prevention activities and treatment services for health conditions related to the Zika virus.