This week in Medicare updates–7/12/2017
Revision to State Operations Manual (SOM) Appendix PP for Phase 2, F-Tag Revisions, and Related Issues
On June 29, CMS posted a memorandum that it will be issuing a revisions to SOM Appendix PP for Phase 2 and to F-Tags and also plans reform of requirements for its Long-Term Care Facilities rule. To address concerns related to the scope and timing of the changes, CMS will be providing limited enforcement remedies for certain Phase 2 provisions and will be holding constant the Nursing Home Compare health inspection rating for one year.
Effective date: November 28, 2017
The Supplemental Security Income (SSI)/Medicare Beneficiary Data for Financial Year (FY) 2015 for Inpatient Prospective Payment System (IPPS) Hospitals, Inpatient Rehabilitation Facilities (IRF), and Long-Term Care Hospitals (LTCH)
On June 30, CMS published Transmittal 1863, which contains instructions to provide updated data for determining the disproportionate share adjustment for IPPS hospitals and the low-income patient adjustment for IRF as well as payments as applicable for LTCH discharges. The SSI/Medicare beneficiary data for hospitals are available electronically and contains the name of the hospital, CMS certification number, SSI days, total Medicare days, and the ratio of days for patients entitled to Medicare Part A attributable to SSI recipients.
MLN Matters 10026 was published July 7 to supplement the transmittal.
Effective date: July 31, 2017
Implementation date: July 31, 2017
Suppression of G9678 (Oncology Care Model Monthly Enhanced Oncology Services) Claims OCM Beneficiary Medicare Summary Notice
On June 30, CMS published Transmittal 175, which rescinds and replaces Transmittal 172, dated May 12, 2017, to suppresses all G9678 (Oncology Care Model Monthly Enhanced Oncology Services) claims from the Medicare Summary Notice (MSN). This includes the billing code, HCPCS service description, claim lines, and all other content elements related to all G9678 codes. G9678 is a model-specific demonstration code that has no beneficiary cost-sharing.
Effective date: October 1, 2017
Implementation date: October 2, 2017
Comment Request: Medical Necessity Disclosure Under The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and Claims Denial Disclosure Under MHPAEA
On July 3, CMS published a Comment Request in the Federal Register around the topics of medical necessity disclosure and claims denial disclosures under the The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and the Public Health Service (PHS) Act were passed. Comments are due September 1.
Comment Request: Medicare Geographic Classification Review Board Procedures and Criteria; Application for Hospital Insurance and Supporting Regulations; and more
On July 6, CMS published a Comment Request in the Federal Register regarding its intention to conduct a survey and collect information pertaining to the Medicare Geographic Classification Review Board Procedures and Criteria; Application for Hospital Insurance and Supporting Regulations; and the CMS Tribal Long-Term Services and Supports (LTSS) Program Survey. Comments are due by September 5.
New Provider Self-Disclosure Settlements and Corporate Integrity Agreements
On July 6, the OIG published information on several new Provider Self-Disclosure Settlements, including:
- Laboratory Corporation of America agreed to pay $45,466 for allegedly violating the Civil Monetary Penalties Law when it allegedly employed an individual that it knew or should have known was excluded from participation in federal healthcare programs.
- Children's National Medical Center in Washington, D.C., agreed to pay $615,263 for allegedly violating the Civil Monetary Penalties Law when it allegedly presented to federal healthcare programs claims for services that it knew or should have known were not provided as claimed and were false or fraudulent.
- Central Maine Medical Center (CMMC), Central Maine Health Care Corporation, and Comprehensive Pharmacy Services (CPS), Inc., of Maine, agreed to pay $196,929 for allegedly violating the Civil Monetary Penalties Law for allegedly having a contract with CPS to staff and manage its hospital pharmacies, employed an individual that CMMC and CPS knew or should have known was excluded from participation in MaineCare, and that no MaineCare program payments could be made for items or services furnished by the individual.
- Tobii Dynavox, LLC, of Pennsylvania, agreed to pay $163,952 for allegedly violating the Civil Monetary Penalties Law provisions applicable to beneficiary inducements and kickbacks when it allegedly improperly induced Medicare and TRICARE beneficiaries to buy Tobii's products by waiving cost-sharing amounts without conducting an individualized determination of financial need.
OIG Report: Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles
On July 6, the OIG published a Report, which found that that the rate of Part D plan formularies' inclusion of the 197 drugs commonly used by dual eligibles is high. Also, 70% of the commonly used drugs are included by all Part D plan formularies. The OIG concluded that inclusion rates for the 197 drugs commonly used by dual eligibles are largely unchanged compared with the inclusion rates listed in our previous reports. Part D formularies include roughly the same percentage of these commonly used drugs in 2017 as they did in 2016.
Comment Request: Prescription Drug Event Data from Contracted Part D providers and more
On July 7, CMS published a Comment Request in the Federal Register regarding the following information collections:
- Application for Enrollment in Medicare the Medical Insurance Program
- Application for Hospital Insurance Benefits for Individuals with End Stage Renal Disease
- Request for Termination of Premium Hospital and Supplementary Medical Insurance
- Prescription Drug Event Data from Contracted Part D Providers for Payment
- Medicaid Payment for Prescription Drugs - Physicians and Hospital Outpatient Departments Collecting and Submitting Drug Identifying Information to State Medicaid Programs
- Retirement benefit information
Comments are due by August 7.
OIG Finds Wisconsin Physicians Service Insurance Corporation (WPS) Owes Missouri Providers Money
On July 7, the OIG published a Report that Wisconsin Physicians Service Insurance Corporation (WPS) did not properly settle for federal fiscal years (FY) 2010 through 2012 Medicare cost reports submitted by inpatient hospitals in Missouri for Medicare disproportionate share hospital (DSH) payments in accordance with federal requirements. OIG recommended that WPS recover the $3 million in Medicare DSH overpayments from the selected Missouri providers, reopen and revise settled cost reports that OIG did not review, and refund overpayments to the federal government.
OIG Advisory Opinion: Waiving Fees for Needy Patients
On July 7, the OIG published an Advisory Opinion in response to a request for an opinion regarding an anonymous hospital outpatient facility’s proposal to reduce or waive, on a non-routine, unadvertised basis, cost-sharing amounts owed by financially needy Medicare beneficiaries for items and services furnished in connection with a clinical research study in a non-profit, full-service, 171-bed regional medical center that provides extensive inpatient and outpatient services. The OIG found that the proposed arrangement would not constitute grounds for the imposition of civil monetary penalties and that the OIG would not impose administrative sanctions although the proposed arrangement could potentially generate prohibited remuneration under the anti-kickback statute.