This week in Medicare updates—10/2/2019
Opioid Use in Medicare Part D in Missouri
On September 23, the OIG published a Data Brief regarding opioid use in Medicare Part D in Missouri as part of its nationwide assessment of opioid use coupled with its specific focus on certain regions. The OIG focused on Missouri because it is the only state that does not currently have a statewide prescription drug monitoring program. The OIG found that 33% of Part D beneficiaries in Missouri received a prescription opioid in 2018, 4% higher than the average of 29% of beneficiaries who received a prescription opioid in 2018. Missouri also had a higher rate of opioid-related overdose deaths than the national average and the number of overdose deaths in Missouri appeared to be increasing while the number of deaths nationwide appear to be decreasing. Nearly 10,000 beneficiaries in Missouri who did not have cancer or were not in hospice care received high amounts of opioids through Part D, a number that indicates opioids may not be medically necessary in some of these cases. The OIG stated it is concerned by the lack of available data on opioids in Missouri as well as the utilization rates in the state.
Comment Request: Bid Pricing Tool for Medicare Advantage Plans and Prescription Drug Plans
On September 23, CMS published a Comment Request in the Federal Register regarding an information collection titled, “Bid Pricing Tool (BPT) for Medicare Advantage (MA) Plans and Prescription Drug Plans (PDP).”
Comments are due by November 22, 2019.
Application from The Compliance Team for Initial CMS Approval of Its Home Infusion Therapy Accreditation Program
On September 23, CMS published a Proposed Notice with Request for Comment in the Federal Register regarding an application from The Compliance Team for initial recognition as a national accrediting organization for suppliers of home infusion therapy services.
Comments on the application are due no later than 5 p.m. on October 23, 2019.
Application from The Compliance Team for Initial CMS Approval of Its Diabetes Outpatient Self-Management Training Accreditation Program
On September 23, CMS published a Notice with Request for Comment in the Federal Register regarding an application from The Compliance Team for initial recognition as a national accrediting organization for entities that wish to furnish diabetes outpatient self-management training services.
Comments on the application are due no later than 5 p.m. on October 23, 2019.
Trump Administration Drives Down Medicare Advantage and Part D Premiums for Seniors
On September 24, CMS published a Press Release regarding Medicare Advantage premiums and enrollment expectations for 2020. The average Medicare Advantage monthly plan premium is expected to decrease from $26.87 in 2019 to $23.00 in 2020, a total decrease of 14%. CMS also expects to have approximately 1200 more Medicare Advantage plans operating in 2020 than in 2018. Enrollment is expected to increase to 24.4 million beneficiaries for 2020, an increase of 30.6% since 2017.
Comment Request: Collection of Diagnostic Data in the Abbreviated RAPS Format from Medicare Advantage Organizations for Risk Adjusted Payments; more
On September 25, CMS published a Comment Request in the Federal Register regarding the following information collections:
- Collection of Diagnostic Data in the Abbreviated RAPS Format from Medicare Advantage Organizations for Risk Adjusted Payments
- Elimination of Cost-Sharing for Full Benefit Dual-Eligible Individuals Receiving Home and Community-Based Services
- Electronic Funds Transfer Authorization Agreement
Comments are due by November 25, 2019.
Final Rule: Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals (CAH), and Home Health Agencies (HHA), and Hospital and CAH Changes to Promote Innovation, Flexibility, and Improvement in Patient Care
On September 25, CMS published a draft version of a Final Rule regarding discharge planning for transitions from acute to post-acute care (PAC). The rule finalizes requirements for hospitals, CAHs, and HHAs to implement discharge planning processes that will provide more information (such as a PAC provider or supplier’s performance in quality measures and resource measures) to patients and their families to help them make more informed decisions about PACs in order to better address their goals for care and treatment preferences. Facilities must meet these requirements in order to participate in Medicare or Medicaid. The rule also includes interoperability requirements that will help ensure patients’ health care information follows them after discharge from a hospital or PAC provider into outpatient and follow-up services.
These changes will be effective 60 days following the rule’s publication in the Federal Register, which is scheduled for September 30. CMS published a Fact Sheet and Press Release on the rule on September 25.
Final Rule: Omnibus Burden Reduction (Conditions of Participation)
On September 25, CMS published a draft version of a Final Rule which finalizes provisions of three separate proposed rules: the Omnibus Burden Reduction proposed rule (dated September 20, 2018); Hospital and Critical Access Hospital Changes to Promote Innovation, Flexibility, and Improvement in Patient Care proposed rule (dated June 6, 2016); and the Fire Safety Requirements for Certain Dialysis Facilities proposed rule (dated November 4, 2016). Some of the provisions of the rule include:
- Changing requirements for emergency program review frequency, decreasing emergency training requirements, and increasing flexibility for the testing requirement for inpatient providers/suppliers to allow facilities to choose one of the two annually-required testing exercises
- Allowing hospitals flexibility in establishing policy for when a pre-surgery/pre-procedure assessment for an outpatient can be utilized and allowing multi-hospital systems to have unified QAPI programs and unified/integrated infection control and antibiotic programs
- Removing assorted requirements for hospital and CAH swing-bed providers and reducing the frequency of certain reviews of policies in CAHs, RHCs, and FQHCs
- Removing requirements in ASCs related to written transfer agreements and physician admitting privileges as well as removing requirements for physicians or qualified practitioners to conduct a complete comprehensive medical history and physical assessment on each patient at least 30 days before the date of a scheduled surgery
The rule also has policies relevant to transplant centers, home health, hospices, comprehensive outpatient rehabilitation facilities, community mental health centers, portable x-ray services, religious nonmedical health care institutions, and fire safety requirements for dialysis facilities.
CMS published a Fact Sheet and Press Release on the rule on the same date. The regulations are effective 60 days after publication in the Federal Register, which is scheduled for September 30, 2019. Implementation dates vary by policy.
Instructions Relating to the Self-Disallowance Requirement for Determining Jurisdiction over Appeals
On September 25, CMS published One-Time Notification Transmittal 2363, which rescinds and replaces Transmittal 2268, dated March 8, 2019, to include instructions on how to address jurisdictional challenges pending before the Provider Reimbursement Review Board that are no longer valid and that the MAC would prefer to pursue administrative resolution. The original transmittal was issued regarding updated directions related to the evaluation of the self-disallowance requirement for determining Provider Reimbursement Review Board and MAC hearing officer jurisdiction over appeals of cost reports.
Effective date: March 8, 2019
Implementation date: March 8, 2019
Revisions to State Operations Manual (SOM), Chapter 6 - Special Procedures for Laboratories
On September 26, CMS published a Memorandum to state survey agency directors regarding revisions to the SOM which will establish quality laboratory policies and procedures intended to assist in ensuring accurate and reliable test results, protecting patients, and improving the quality of health care.
Effective date: Immediately. This policy should be communicated with all survey and certification staff, their managers, and the state/regional office training coordinators within 30 days of this memorandum.
Comment Request: Medicare Enrollment Application for Clinics/Group Practices and Other Suppliers
On September 26, CMS published a Comment Request in the Federal Register regarding an information collection titled, “Medicare Enrollment Application for Clinics/Group Practices and Other Suppliers.”
Comments are due by November 25, 2019.
Patient Safety Organizations: Hospital Participation, Value, and Challenges
On September 27, the OIG published a Review on the extent to which hospitals participate in Patient Safety Organization (PSO) programs and their perspectives on the values and challenges of participation. The OIG found that over half of the general acute care hospitals surveyed work with a PSO and nearly all of them found it valuable. Among those who worked with a PSO, 80% of acute care hospitals found the PSO’s feedback helped prevent future patient safety events. Of the hospitals who did not participate, nearly all said that the PSO program would be redundant relative to other patient safety efforts, and the program’s legal and information protections caused uncertainty or challenges for hospitals, thereby discouraging them from disclosing data to PSOs or participating at all. Other technological challenges also proved to be a barrier for participation. The OIG recommends the AHRQ do more to support and promote the PSO program. It specifically recommends the AHRQ develop a communications strategy to increase awareness of the program and its value, take steps to encourage PSOs to participate by including more data formats for the Network of Patient Safety Databases (NPSD), and update guidance for PSOs on processes for listing PSOs.
Revisions to Part 1, Chapter 22 of Provider Reimbursement Manual
On September 27, CMS published Provider Reimbursement Transmittal 479 regarding updates to Section 2231 of the manual for regional Medicare swing-bed SNF rates. Changes include revised language in the initial paragraph of that section and a new Table 31 to update payment rates for routine SNF-type services provided by swing-bed hospitals during CY 2020. These should be used to carve out swing-bed costs on the hospital cost report.
Effective date: For services furnished on or after January 1, 2020
Provider Enrollment Rebuttal Process
On September 27, CMS published Medicare Program Integrity Transmittal 904 regarding implementation of a new provision in the Code of Federal Regulations which permits providers/suppliers whose Medicare billing privileges were deactivated to file a rebuttal. The transmittal also explains the role MACs will play in this process.
Effective date: December 31, 2019
Implementation date: December 31, 2019
January 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
On September 27, CMS published Medicare Claims Processing Transmittal 4404 regarding the quarterly update to the ASP and Not Otherwise Classified drug pricing files for Part B drugs.
Effective date: January 1, 2020
Implementation date: January 6, 2020
Updates to Chapters 3, 4, 8, 15, and Exhibits of Publication 100-08
On September 27, CMS published Medicare Program Integrity Transmittal 902 regarding changes to various chapters in the Program Integrity Manual based on updates to Unified Program Integrity Contractor (UPIC) and Investigations Medicare Drug Integrity Contractor (I-MEDIC) processes and procedures. These changes are related to prepayment review processes, the purpose of I-MEDIC investigations, information that must be provided to various agencies and departments, and more.
Effective date: October 28, 2019
Implementation date: October 28, 2019
Update to Chapter 12 (The Comprehensive Error Rate Testing [CERT] Program) of Publication 100-08
On September 27, CMS published Medicare Program Integrity Transmittal 905 regarding updated guidance that states any cancellations, adjustments, or other actions that occur on the date of the transaction file are not applicable to CERT program reporting.
Effective date: December 30, 2019
Implementation date: December 30, 2019
Nationwide Genetic Testing Fraud
On September 27, the OIG published a handful of Resources regarding a nationwide genetic testing fraud scheme, which caused $2.1 billion in losses. The HHS OIG and law enforcement announced charges against 35 individuals associated with dozens of telemedicine and cancer genetic testing laboratories across Georgia, Florida, Louisiana, and Texas for their alleged participation in the scheme. In addition, CMS and the Center for Program Integrity announced that it took action against cancer genetic testing companies and medical professionals who submitted more than $1.7 billion in claims to Medicare. The scheme involved recruiters who would target elderly and/or disabled beneficiaries to submit to cancer genetic testing. A doctor would then order a test for the beneficiary (even if not medically necessary) and would receive a kickback from the recruiter for doing the test. The lab would then run the test and receive reimbursement for it from Medicare. The lab would share the proceeds of that payment with the recruiter.
CMS published a Press Release from the Department of Justice, a Graphic explaining how the scheme worked, a Consumer Alert about the scheme, and more.
