This week in Medicare updates–12/21/2016
Long-Term Care (LTC) Regulation: Enforcement of Rule Prohibiting Use of Pre-Dispute Binding Arbitration Agreements is Suspended so Long as Court Ordered Injunction Remains in Effect
On December 9, CMS released a Memorandum regarding the suspended enforcement of the new rule prohibiting skilled nursing facilities, nursing facilities and dually-certified facilities from using pre-dispute binding arbitration agreements while there is a court-ordered injunction in place prohibiting enforcement of this provision.
New York Physician Agrees to 5 Year Exclusion
On December 9, the OIG posted information regarding Michael Esposito, MD, who agreed to be excluded from participation in all federal healthcare programs for five years after an OIG investigation revealed he forged the signature of another physician on prescriptions for medications for himself and another person that were paid for by the Medicare program.
Hospital Appeals Settlement Process FAQs Updated
On December 12, CMS posted updated FAQs related to the 2016 Hospital Appeals Settlement for Fee-For-Service Denials Based on Patient Status Reviews for Admissions Prior to October 1, 2013.
Long-Term Care Hospital Compare Website
On December 14, CMS posted a Fact Sheet regarding the Long-Term Care Hospital Compare website that was launched on December 14, 2016.
Inpatient Rehabilitation Facility (IRF) Compare Website
On December 14, CMS posted a Fact Sheet regarding the Inpatient Rehabilitation Facility Compare website that was launched on December 14, 2016.
OIG 2016 Year in Review
On December 14, the OIG posted its Eye on Oversight video recapping its work in 2016, including topics the largest healthcare fraud takedown in history. An OIG 2016 Year in Review is also available in Podcast form.
Revisions to State Operations Manual (SOM) Appendix W - Survey Protocol, Regulations and Interpretive Guidelines for Critical Access Hospitals (CAH) and Swing-Beds in CAHs
On December 14, CMS published Transmittal 165 regarding revisions to the regulation language for CAH providers of emergency services in 2004 and 2006. Standards §485.618(d)(1) through §485.618(d)(4) are being revised to reflect the current regulations. In addition, language has been added to the survey procedures.
Effective date: December 16, 2017
Implementation date: December 16, 2017
Conditions for Coverage for End-Stage Renal Disease Facilities—Third Party Payment interim final rule
On December 14, CMS published an interim final rule the Federal Register to implement new requirements for Medicare-certified dialysis facilities that make payments of premiums for individual market health plans. These requirements apply to dialysis facilities that make such payments directly, through a parent organization, or through a third party. Comments are due by January 11, 2017.
Effective date: January 13, 2017
Comment Request: Conditions of Participation--Requirements for Approval and Reapproval of Transplant Centers to Perform Organ Transplants; QIO Assumption of Responsibilities and Supporting Regulations
On December 14, CMS published a Comment Request in the Federal Register regarding the Quality
Improvement Organization (QIO) assumption of responsibilities and supporting regulations as well as the Conditions of Participation related to requirements for approval and reapproval of transplant centers to perform organ transplants.
Implementation of Changes in the End-Stage Renal Disease (ESRD) Prospective Payment System and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for Calendar Year 2017
On December 15, CMS published Transmittal 231, which rescinds and replaces Transmittal 229, dated November 4, 2016, to revise business requirement 9807.9, delete requirement 9807.11.2, and add requirement 9807.13. The Provider Education requirement number is now 9807.14.
Effective date: January 1, 2017
Implementation date: January 3, 2017
Comprehensive Primary Care Plus (CPC+) 2018 Payer and Practice Solicitation
On December 15, CMS published a Fact Sheet regarding the Comprehensive Primary Care Plus (CPC+) advanced primary care medical home model announced April 11, 2016. The first round of this five-year multi-payer model will begin in January 2017 and run through 2021. CMS will also offer a second round of CPC+ to begin in January 2018 and run through 2022.
CMS announces additional opportunities for clinicians under the Quality Payment Program
On December 15, CMS published a Press Release regarding new opportunities for clinicians to join Advanced Alternative Payment Models (APM) to improve care and earn additional incentive payments under the Quality Payment Program, which implements the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Beginning in January and February 2017, CMS will open applications for new rounds of two CMS Innovation Center models for the 2018 performance year.
New Medicare-Medicaid ACO Model
On December 15, CMS published a Press Release and associated Fact Sheet announcing the Medicare-Medicaid Accountable Care Organization (ACO) Model, a new initiative designed to improve the quality of care and lower costs for beneficiaries enrolled in both Medicare and Medicaid. The Medicare-Medicaid ACO Model will allow Medicare Shared Savings Program ACOs to take on accountability for the quality of care and both Medicare and Medicaid costs for Medicare-Medicaid enrollees.
Notice of Benefit and Payment Parameters final rule and the final Annual Letter to Issuers for 2018
On December 16, CMS published the Notice of Benefit and Payment Parameters final rule and the final Annual Letter to Issuers for 2018. The final rule establishes standards for issuers and each Health Insurance Marketplace, generally for plan years that begin on or after January 1, 2018, according to the associated Fact Sheet. A Press Release regarding the announcement is also available.
Instructions to Hospitals on the Election of a Medicare-Supplemental Security Income (SSI) Component of the Disproportionate Share (DSH) Payment Adjustment for Cost Reports that Involve SSI Ratios for Fiscal Year (FY) 2004 and Earlier, or SSI Ratios for Hospital Cost-Reporting Periods for Patient Discharges Occurring Before October 1, 2004
On December 16, CMS published Transmittal 279 to direct the contractors to inform hospitals of the requirements for making an election for a particular fiscal period covered by the CMS Ruling 1498-R (modified by CMS Ruling 1498-R2 dated April 22, 2015).
Effective date: January 19, 2017
Implementation date: January 19, 2017
Continuation of the Home Health Probe and Educate Medical Review Strategy
On December 16, CMS published Special Edition MLN Matters SE1635 regarding Round 2 of medical review and reporting under the Home Health Probe & Educate medical review strategy. These reviews relate to claims submitted by HHAs related to Medicare home health services and patient eligibility (certification/re-certification), as outlined in CMS-1611-F, the Calendar Year (CY) 2015 Home Health Prospective Payment System (HH PPS) Final Rule. This final rule eliminated the face-to-face encounter narrative as part of the certification of patient eligibility for home health services.
For round 2 of the Probe and Educate program, CMS anticipates MACs will begin sending Additional Documentation Requests (ADR) on or after December 15, 2016, and that this round of claim reviews and provider education will conclude in approximately one year.
CMS is directing Home Heath MACs to select a sample of 5 claims for prepayment review for from each HHA within their jurisdiction, excluding those providers who had 5 claims reviewed in Round 1, with zero or one claim in error. MACs will continue to focus on the compliance with the policy outlined in the 2015 HH PPS final rule, as well as ensuring all other coverage and payment requirements are met.
Payment for Oxygen Volume Adjustments and Portable Oxygen Equipment
On December 16, CMS published Transmittal 3679, which rescinds and replaces Transmittal 3649, dated November 10, 2016, to update the manual attachment. The Transmittal is in regards to instructions for Medicare contractors involved in processing claims for oxygen and oxygen equipment under the Medicare Part B benefit for durable medical equipment.
Effective date: April 1, 2017
Implementation date: April 3, 2017
Shared Savings Program (SSP) Accountable Care Organization (ACO) Qualifying Stay Edits
On December 16, CMS published Transmittal 1763, which rescinds and replaces Transmittal 1683, dated July 21, 2016, to update the specification that the TIN should not be blank. The requirement originally indicated the TIN should be blank. All other information remains the same. The associated MLN Matters 9568 was also revised to account for the updated transmittal number, CR release date, and links.
Effective date: January 1, 2017
Implementation dates:
October 3, 2016 - Split over October 2016 and January 2017. Full implementation is in January 2017.
January 3, 2017 - Split over October 2016 and January 2017. Full implementation is in January 2017.
Prolonged Services Without Direct Face-to-Face Patient Contact Separately Payable Under the Physician Fee Schedule (Manual Update)
On December 16, CMS published Transmittal 3678 and MLN Matters 9905 to revise Chapter 12, Section 30.6.15.2 of the Medicare Claims Processing Manual to indicate that beginning Calendar Year 2017, CPT codes 99358 and 99359 (prolonged services without face-to-face contact) are separately payable under the Medicare Physician Fee Schedule.
Effective date: January 1, 2017
Implementation date: January 3, 2017
Provider Reimbursement Manual - Part 1, Chapter 22, Determination of Cost of Services to Beneficiaries
On December 16, CMS published Transmittal 473 to add a crosswalk to clarify the numbering of regions referenced in the Provider Reimbursement Manual - Part 1, Chapter 22, Determination of Cost of Services to Beneficiaries, with the numbering of divisions identified by the Bureau of the Census. The names of each division and the states that are included in each division are provided for further clarification.
Contacting Non-Responders and Documentation Requests
On December 16, CMS published Transmittal 691 to update Chapter 12 of the Medicare Program Integrity Manual, Pub. 100-08, which instructs Medicare Administrative Contractors (MAC) on how to proceed in response to the display of Error Code 99 on the Comprehensive Error Rate Testing (CERT) Claims Status Website.
Effective date: January 19, 2017
Implementation date: January 19, 2017
Summary of Policies in the Calendar Year (CY) 2017 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, and CT Modifier Reduction List
On December 16, CMS published Transmittal 3676 and MLN Matters 9844 to provide a summary of policies in the 2017 MPFS Final Rule and announce the Telehealth Originating Site Facility Fee payment amount.
Effective date: January 1, 2017
Implementation date: January 3, 2017
Comment Request: Conditions of Participation for Comprehensive Outpatient Rehabilitation Facilities and Supporting Regulations; Elimination of Cost-Sharing for Full Benefit Dual-Eligible Individuals Receiving Home and Community-Based Services; and more
On December 16, CMS published a Comment Request in the Federal Register regarding several information collections, including:
- CCMS–10198 Creditable Coverage Disclosure to CMS On-Line Form and Instructions
- CMS–10344 Elimination of Cost-Sharing for Full Benefit Dual-Eligible Individuals Receiving Home and Community-Based Services
- CMS–10501 Healthcare Fraud Prevention Partnership HFPP Data Sharing and Information Exchange
- CMS–10282 Conditions of Participation for Comprehensive Outpatient Rehabilitation Facilities and Supporting Regulations
Comment Request: End Stage Renal Disease Medical Information Facility Survey
On December 16, CMS published a Comment Request in the Federal Register regarding the ESRD Program Management and Medical Information System (PMMIS) Facility Certification/Survey Record, which contains provider-specific and aggregate patient population data on beneficiaries treated by that provider obtained from the Annual Facility Survey form (CMS– 2744).
Start-Up Funding in Support of the Vermont All-Payer Accountable Care Organization (ACO) Model—Cooperative Agreement
On December 16, CMS published a Notice in the Federal Register to announce issuance of the November 23, 2016, single-source cooperative agreement funding opportunity available solely to Vermont’s Agency of Human Services in order to provide care coordination and bolster collaboration for practices and community-based health care providers as part of the Vermont All-Payer Accountable Care Organization (ACO) Model.