This week in Medicare updates—10/24/18

October 24, 2018
Medicare Insider

Activation of Systemic Validation Edits for OPPS Providers with Multiple Service Locations

On October 12, CMS published Special Edition MLN Matters 18023 regarding the activation of systematic validation edits for service facility locations. The article includes information on what providers that have multiple service locations should report on the claim level and on the line item level. CMS conducted the first round of testing on edits for service location validation in July, and it will perform additional testing in November.    

Effective date: N/A

Implementation date: N/A


Updated Corporate Integrity Agreement Documents

On October 15, the OIG published information on three new Corporate Integrity Agreements, including:


Updated OIG Work Plan

On October 15, the OIG updated its Work Plan with the following new item:


Updated Civil Monetary Penalties and Affirmative Exclusions

On October 17, the OIG published an updated List of Civil Monetary Penalties and Affirmative Exclusions agreements, including:

  • On October 3, Ronald Burns, M.D., of Phoenix, Arizona, reached a $75,409.15 settlement with the OIG to resolve allegations that Dr. Burns entered into contracts and received remuneration from Millennium Health, LLC f/k/a Millennium Laboratories, Inc., in the form of point of care test cups which resulted in prohibited referrals.
  • On October 5, Healthways Worldwide Inc. d/b/a Healthways Pharmacy and Surgical, of Brooklyn, New York, reached a $204,426.64 settlement with the OIG to resolve allegations of employing an individual who was excluded from participating in federal healthcare programs.


CY 2019 Inpatient Hospital Deductible and Hospital and Extended Care Services Coinsurance Amounts

On October 17, CMS published a Notice in the Federal Register regarding the inpatient hospital deductible and hospital and extended care services coinsurance amounts under Part A for 2019. The inpatient hospital deductible will be $1,364. Daily coinsurance will be $341 for the 61st through 90th day of hospitalization, $682 for lifetime reserve days, and $170.50 for the 21st through 100th day of extended care services in a skilled nursing facility.

Effective date: January 1, 2019


CY 2019 Part A Premiums for the Uninsured Aged and for Certain Disabled Individuals Who Have Exhausted Other Entitlements

On October 17, CMS published a Notice in the Federal Register regarding the Part A premium for uninsured enrollees in CY 2019. The monthly Part A premium for these individuals will be $437 starting January 1, 2019. The premium for certain other individuals described in the notice will be $240.

Effective date: January 1, 2019


Medicare Part B Monthly Actuarial Rates, Premium Rates, and Annual Deductible Beginning January 1, 2019

On October 17, CMS published a Notice in the Federal Register regarding monthly actuarial rates for aged and disabled beneficiaries enrolled in Part B of the Medicare Supplementary Medical Insurance Program for CY 2019 as well as a variety of other rates and deductible amounts. These rates include:

  • Monthly actuarial rate: $264.90 for aged enrollees, $315.40 for disabled enrollees
  • Standard monthly Part B premium rate: $135.50 for all enrollees
  • Part B deductible: $185.00 for all Part B beneficiaries

The notice also contains information on payments for beneficiaries who have to pay an income-related monthly adjustment.

Effective date: January 1, 2019


Proposed Rule: Regulation to Require Drug Pricing Transparency

On October 18, CMS published a Proposed Rule in the Federal Register regarding drug pricing transparency. The rule would require any direct-to-consumer television advertisement for a prescription drug or biological with payment available through Medicare or Medicaid to include the wholesale acquisition cost of the product in the advertisement. The price required to be posted would be for a typical course of a medication used in treatment for an acute condition or for the 30-day supply of medication for a chronic condition. The rule includes an exemption for any prescription drug or biological that costs less than $35 per month or per typical course of treatment.

CMS published a Press Release on the rule on October 15. Comments on the proposed rule are due no later than 5 p.m. on December 17, 2018.


Qualifying Alternative Payment Model Participants Methodology Fact Sheet

On October 18, CMS published a Fact Sheet regarding its process for identifying eligible clinicians who can participate in advanced alternative payment models (APM) as qualifying participants, meaning these clinicians are eligible to receive the 5% APM incentive payment through the Quality Payment Program.


Provider Reimbursement Manual Part 2, Provider Cost Reporting Forms and Instructions, Chapter 40, Form CMS-2552-10

On October 19, CMS published Provider Reimbursement Manual Transmittal 15 regarding updates to Chapter 40, Hospital and Hospital Health Care Complex Cost Report, by accommodating select provisions of the Bipartisan Budget Act of 2018 and the 2019 IPPS and Long-Term Care Hospital PPS final rule.  

Effective date: Cost Reporting Periods Ending On or After September 30, 2018


Magnetic Resonance Imaging (MRI)

On October 19, CMS published Medicare National Coverage Determinations Transmittal 208 and Medicare Claims Processing Transmittal 4147 regarding new coverage of MRIs for beneficiaries under certain conditions. Medicare will allow coverage of MRIs for beneficiaries with implanted pacemakers, implantable cardioverter defibrillators, cardiac resynchronization therapy pacemakers, and cardiac resynchronization therapy defibrillators in patients undergoing MRIs both on and off FDA label.  

Effective date: April 10, 2018

Implementation date: December 10, 2018


Medical Review of Diagnostic Laboratory Tests

On October 19, CMS published Medicare Program Integrity Transmittal 836 regarding instructions to medical review contractors on how to review orders for diagnostic laboratory tests.  

Effective date: November 21, 2018 - Reviews conducted on/after 30 days from issuance

Implementation date: November 21, 2018 - Reviews conducted on/after 30 days from issuance