This week in Medicare updates—10/12/2022
UPICs Hold Promise to Enhance Program Integrity Across Medicare and Medicaid, But Challenges Remain
On October 3, the OIG published a Review of how the Unified Program Integrity Contractors (UPIC) are doing in their duties to safeguard program integrity across both Medicare fee-for-service and the Medicaid programs. The OIG reviewed workload data related to program integrity activities for all five UPICs in 2019. It also sought feedback from CMS on the effects of the unification of the Medicare and Medicaid program integrity activities, how CMS measures the effectiveness of UPICs, and what challenges UPICs may face in conducting their work. While much of the data reviewed was based on UPIC performance in 2019, the OIG also asked both UPICs and CMS about the effects of the COVID-19 pandemic on the UPICs’ work.
The OIG found that UPICs conducted substantially more program integrity activities in Medicare than in Medicaid, as UPICs faced issues with Medicaid data availability and quality, and they also had to confront differences across states’ Medicaid policies and regulations. It said that strategies for unifying Medicare and Medicaid data to improve program integrity have yet to yield significant results. The OIG did note that CMS and UPICs have created a foundation for improvements through collaborative processes, analytical tools, and new technologies across the UPICs. This includes the Unified Case Management system (UCM) and Major Case Coordination initiative (MCC). Despite challenges posed by the COVID-19 pandemic, UPICs were able to continue program integrity activities with some limitations.
The OIG recommends CMS implement a plan to increase UPICs’ Medicaid program integrity activities–especially related to managed care. It also recommended CMS make improvements to the UCM system, implement a plan to help ensure the success of the MCC for Medicaid referrals, and identify the reasons for any unexplained variations in program integrity activities across UPICs. CMS concurred with the recommendations.
National Expansion of the Repetitive, Scheduled, Non-Emergent Ambulance Transport (RSNAT) Prior Authorization Model
On October 3, CMS revised an MLN Fact Sheet regarding the RSNAT Prior Authorization model to add information on how CMS processes claims when a provider/supplier elects to bypass prior authorization. The fact sheet reviews information on participation in this model, how to request prior authorization, what certain types of decisions mean, and more.
OIG Advisory Opinion No. 22-19
On October 5, the OIG published an Advisory Opinion regarding whether a proposed arrangement where a pharmaceutical manufacturer would subsidize operating costs and certain types of cost-sharing and premium subsidies for Part D enrollees would be grounds for the imposition of sanctions under the civil monetary penalties, beneficiary inducements, or anti-kickback sections of the Social Security Act. The arrangement would involve pharmaceutical manufacturers of oncology drugs joining together as funding manufacturers who would subsidize three different categories of costs:
- Cost-sharing incurred by eligible Part D enrollees when filling prescriptions for that funding manufacturer’s Part D oncology drugs
- Specified programs (such as those trying to increase health equity in clinical trial participation) and certain beneficiaries’ health insurance premiums
- Operating costs for the Opinion’s requestor
Details on exactly how this program would run and be administered are included in the Opinion. The OIG determined that this arrangement would generate prohibited remuneration under the civil monetary penalties in sections 1128A(7) and 1128(b)(7) of the Social Security Act and therefore would be grounds for the imposition of sanctions in that area. It would not, however, constitute grounds for the imposition of sanctions under the beneficiary inducements civil monetary penalty. The OIG said any conclusion regarding the existence of a federal anti-kickback statute violation would require knowledge of the party’s intent, which it said was beyond the scope of this advisory opinion process. While it reached no definitive conclusion on that, the OIG mentioned multiple elements of concern about this arrangement throughout the Opinion.
Comment Request: Medicare Advantage and Prescription Drug Program: Final Marketing Provisions in 42 CFR 422.111(a)(3) and 423.128(a)(3); more
On October 5, CMS published a Comment Request in the Federal Register regarding the following information collections:
- Medicare Advantage and Prescription Drug Program: Final Marketing Provisions in 42 CFR 422.111(a)(3) and 423.128(a)(3)
- Bid Pricing Tool (BPT) for Medicare Advantage (MA) Plans and Prescription Drug Plans (PDP)
Comments are due by December 5.
ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs)--January 2023 Update
On October 5, CMS published One-Time Notification Transmittal 11636, which rescinds and replaces Transmittal 11546, dated August 4, to remove ICD-10 diagnosis codes added in error to NCD 150.3, business requirement 12842.4, and to restore ICD-10 diagnosis code C91.92 removed in error to NCD 110.23, business requirement 12842.3. The original transmittal was published regarding the maintenance update of ICD-10 conversions and other coding updates for NCDs.
CMS revised MLN Matters 12842 on the same date to accompany the transmittal.
Effective date: January 1, 2023 - or as noted in the individual business requirements
Implementation date: September 6, 2022 - business requirements 12842.2, 12842.8; January 3, 2023
Fact Sheet on Inflation Reduction Act Changes for Medicare
On October 5, CMS published a Fact Sheet regarding provisions in the Inflation Reduction Act that will affect Medicare and other federal health care programs. Some of these include a yearly cap on out-of-pocket payments for prescription drugs for people with Medicare prescription drug coverage, a requirement for Medicare to negotiate prescription drug prices for 10 drugs from a list of the highest-spending, brand name Part D drugs which don’t have competition, the creation of a manufacturer discount program in Medicare, and more.
CMS published a Timeline for when the changes will happen, FAQs on the impact on drug prices and Medicare, and a Statement from HHS Secretary Xavier Becerra and CMS Administrator Chiquita Brooks-LaSure on the same date.
Instructions to the FISS to Add Additional Multiple Procedure Indicators 6 and 7 into the Physician Fee Schedule Payment Policy Indicator File Record Layout
On October 6, CMS published Medicare Claims Processing Transmittal 11630 regarding instructions to the FISS to add additional multiple procedure indicators 6 and 7 into the Physician Fee Schedule Payment Policy Indicator File Record Layout. These codes are currently payable on professional claims on a fee schedule basis and institutional claims for critical access hospital services on a cost basis. This transmittal will allow codes to be loaded but will not affect the cost-based payment on CAH claims.
Effective date: April 1, 2023
Implementation date: April 3, 2023
New FISS Consistency Edit to Validate Attending Physician National Provider Identifier (NPI)
On October 6, CMS published Medicare Claims Processing Transmittal 11633 regarding implementation of a consistency edit to validate that the attending physician NPI is not being fictitiously substituted with an organizational NPI to bypass HIPAA standards.
CMS published MLN Matters 12889 on the same date to accompany the transmittal. The MLN article lists exceptions in which a billing provider NPI can be used in the data element, such as for COVID-19/influenza/PPV shots with condition code A6 is present, claims in which only screening mammography services are billed with revenue code 0403, and more.
Effective date: April 1, 2023
Implementation date: April 3, 2023
CMS Releases 2023 Medicare Advantage and Part D Star Ratings
On October 6, CMS published a News Alert regarding the star ratings for 2023 Medicare Advantage and Part D Prescription Drug Plans. Approximately 51% of Medicare Advantage plans offering prescription drug coverage in 2023 will have at least a four-star rating. The average star rating for all Medicare Advantage plans with prescription drug coverage is 4.15% for 2023, a decrease from the 2022 average of 4.37%.
CMS published a Fact Sheet on the star ratings on the same date.
Updated List of Lab Tests Subject to Exceptions to the Lab Date of Service (DOS) Policy
On October 6, CMS published a Download Link to an updated list of lab tests subject to exceptions to the lab DOS policy.
Provider Enrollment Appeals and Rebuttals - Revised Instructions and Model Letters
On October 7, CMS published Medicare Program Integrity Transmittal 11637 regarding clarifications of MAC procedures for processing provider enrollment appeals and rebuttals. The transmittal also clarifies MAC external monthly reporting requirements for rebuttals and appeals, provides clarifying instructions regarding model letters, and creates additional appeals and rebuttals model letters.
Effective date: December 9, 2022
Implementation date: December 9, 2022
Request for Information: National Directory of Healthcare Providers & Services
On October 7, CMS published a Request for Information in the Federal Register regarding the establishment of a national directory of healthcare providers and services to serve as a centralized data hub for healthcare provider, facility, and entity directory information nationwide. CMS is seeking comment as to how consolidating this data could help improve access to care and whether it would reduce directory maintenance burden on providers and payers.
CMS published a Press Release on the RFI on October 5. Comments are due no later than 5 p.m. on December 6.