This week in Medicare updates–7/19/2017
Florida Pharmacy Settles Excluded Individual Case
On June 20, Linton Square Pharmacy & Medical Supplies, Inc., of Delray Beach, Florida, entered into a $339,956.05 settlement agreement with the OIG. The settlement agreement resolves allegations that Linton Square employed an individual who was excluded from participating in any federal healthcare programs.
HMS Provider Portal Contact Customization
On July 5, HMS, issued an Announcement that the HMS Provider Portal is available for all Region 4 providers in the JL, JE, and JF Medicare Administrative Contractor (MAC) regions to customize their contact information, along with Provider Portal User Guides.
HMS also announced that it has received CMS approval to initiate review in the Novitas JL MAC Region.
Revision of Civil Money Penalty (CMP) Policies and CMP Analytic Tool
On June 7, CMS issued a memorandum that revises the CMP analytic tool. The memorandum examines:
- Past noncompliance
- Per instance CMP is the default for noncompliance existed before the survey
- Per day CMP is the default for noncompliance existing during the survey and beyond
- Revisit timing
- Review of high CMPs
This policy memo is to replace S&C Memo 15-16-NH; the prior versions of the CMP Tool are now obsolete.
Effective date: July 17, 2017
Delay of Effective Date: Conditions of Participation for Home Health Agencies
On July 10, CMS issued a delay of effective date in the Federal Register that delays the effective date for the “Conditions of Participation for Home Health Agencies” final rule published January 13, 2017. This rule delays the effective date for an additional 6 months until January 13, 2018.
Effective date: January 13, 2018
Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS)
On July 11, CMS published Transmittal 199 and Transmittal 3805, which rescind and replace Transmittal 196 and Transmittal 3787, issued May 26. In the NCD Manual, the reference to Pub 100-04, Chapter 32, and Section 68 needs to be changed to Section 69. In the Medicare Claims Processing Manual, the reference in Pub. 100-04, Chapter 32, Section 68, is changed to Section 69 and adds clarifying language to be added to indicate that CMS will cover procedure code 0275T for PILD only when the procedure is performed within any other Coverage with Evidence Development (CED)-approved randomized and non-blinded clinical trial.
Effective date: December 7, 2016
Implementation date: August 11, 2017
Notice of New Interest Rate for Medicare Overpayments and Underpayments - 4th Quarter Notification for Fiscal Year (FY) 2017
On July 11, CMS published Transmittal 289, to update the private consumer rate to 10.12%, which is the amount of interest the organization will apply to Overpayments and Underpayments to Medicare. Then, on July 13, CMS published Transmittal 291, which rescinds and replaces Transmittal 289, to correct the interest to 10.125%.
Effective date: July 18, 2017
Implementation date: July 18, 2017
New Corporate Integrity Agreements
On July 12, the OIG published information on several new Corporate Integrity Agreement Documents, including:
- Life Watch Services, Inc., of Rosemont, IL.
- American Healthcare Dynamic, LLC, of Evansville, IN.
- Chun, Steven, M.D.; Sarasota Pain Associates, P.A., of Lakewood Ranch, FL.
- Merck & Co., Inc., of Whitehouse Station, NJ.
Correction: Reform of Requirements for Long-Term Care Facilities Final Rule
On July 13, CMS issued a correction in the Federal Register making numerous corrections to the “Reform of Requirements for Long-Term Care Facilities” final rule published October 4, 2016. The correction addresses multiple typographical and technical errors. CMS is waiving the 30-day delay in effective date for this correcting amendment.
Effective date: July 13, 2017
2018 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule
On July 13, CMS released its 2018 OPPS and ASC payment system proposed rule to implement changes arising from continuing experience with these systems and certain provisions under the 21st Century Cures Act. This proposed rule also contains provisions that would update and refine the requirements for the Hospital Outpatient Quality Reporting (OQR) Program and the ASC Quality Reporting (ASCQR) Program.
CMS has also released a Proposed Rule Claims Accounting for OPPS, a Press Release, and a Fact Sheet to accompany the proposed rule.
Comments are due September 11, 2017.
2018 Medicare Physician Fee Schedule (MPFS) and Other Revisions to Part B for Calendar Year (CY )2018; Medicare Shared Savings Program Requirements; and Medicare Diabetes Prevention Program proposed rule
On July 13, CMS published the 2018 MPFS proposed rule that includes proposed provisions to update to the MPFS and Medicare Part B payment systems for calendar year 2018. The provisions in the rule would, if finalized, impact the factors used to determine the MPFS and make other revisions to Medicare Part B for CY 2018, and seeks to expand the current Medicare Diabetes Prevention Program.
CMS also issued supporting documentation as well as a Press Release and two Fact Sheets (with one pertaining more to the Diabetes Prevention Program).
Comments are due September 11, 2017.
OIG Study on Opioids in Medicare Part D
On July 13, the OIG posted the conclusions of a study “Medicare Part D: Concerns about Extreme Use and Questionable Prescribing.” The study’s findings included:
- One in three Medicare Part D beneficiaries received a prescription opioid in 2016
- About 500,000 beneficiaries received high amounts of opioids
- Almost 90,000 beneficiaries are at serious risk; some received extreme amounts of opioids, while others appeared to be doctor shopping
- About 400 prescribers had questionable opioid prescribing patterns for beneficiaries at serious risk; these patterns are far outside the norm and warrant further scrutiny
The OIG concludes that prescribers need to be given the information and tools necessary to make appropriate choices when prescribing opioids, and federal agencies must work together to combat the current opioid crisis.
Federal Healthcare Fraud Takedown
On July 13 the OIG announced that it had, in partnership with state and federal law enforcement, participated in the largest healthcare fraud takedown in history. More than 400 defendants in 41 federal districts were charged with participating in fraud schemes involving about $1.3 billion in false billings to Medicare and Medicaid. OIG also issued exclusion notices to 295 doctors, nurses, and other providers based on conduct related to opioid diversion and abuse.
Health Insurance Portability and Accountability Act (HIPAA) Electronic Data Interchange (EDI) Front-End Updates for January 2018
On July 14, CMS published Transmittal 1865, which provides the Calendar Year (CY) 2018 Common Edits and Enhancements Module (CEM) edits for the Part A and Part B Medicare Administrative Contractors (A/B MAC) and the Common Electronic Data Interchange (CEDI) contractor. Additionally, it will direct Shared Systems to appropriately update the CEM.
Along with the transmittal, several spreadsheets were included as attachments. The spreadsheets document all of the edits to date, as well as those edits which are changed, deleted, or added. The spreadsheets direct contractors to changes they must make for the quarter.
Effective date: January 1, 2018
Implementation date: January 2, 2018
New Specialty Code for Pharmacy
On July 14, CMS published Transmittal 290 announcing a new specialty code being added for pharmacy to align with the CMS-855B paper form. The new speciality code for Pharmacy is (A5).
Effective date: January 1, 2018
Implementation date: January 2, 2018
Fiscal Year (FY) 2018 and After Payments to Skilled Nursing Facilities (SNF) That Do Not Submit Required Quality Data
On July 14, CMS published Transmittal 67, which announces that, starting in FY 2018, if an SNF does not submit required quality data, their payment rates for the year will be reduced by 2% for that fiscal year. Application of the 2% reduction may result in an update that is less than zero for a fiscal year and in payment rates for a fiscal year being less than such payment rates for the preceding fiscal year. In addition, reporting-based reductions to the market basket increase factor will not be cumulative; they will only apply for the FY involved.
Effective date: August 14, 2017
Implementation date: August 14, 2014
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Edits
On July 14, CMS published Transmittal 3807, which announces the quarterly update to the NCCI PTP Edits. The update applies to the Medicare Claims Processing Manual, Pub. 100-04, Chapter 23, Section 20.9. A test file will be available on or about August 2, 2017, and a final file will be available on or about August 17, 2017.
Effective date: October 1, 2017
Implementation date: October 2, 2017
Hospital Outpatient Panel (HOP) Meeting Presentation and Comment Deadline Extended
On July 14, CMS has extended the deadline to submit presentations, comments, and Form CMS-20017 for the upcoming August 21-22 panel meeting. The deadline has been extended to July 28, 2017.