This week in Medicare updates—10/3/2018
Medicare Preventive Services Educational Tool
On September 24, CMS published a new Educational Tool regarding Medicare Preventive Services. The tool contains a grid users can click on to learn more about specific preventive services, the ICD-10 and HCPCS/CPT codes for that service, coverage and frequency determinations for the service, and what the Medicare beneficiary is expected to pay for the service. The tool also contains a frequently asked questions section and a listing of additional resources to learn more about preventive services.
2018-2019 Influenza (Flu) Resources for Health Care Professionals
On September 24, CMS published Special Edition MLN Matters 18015 regarding information about the flu resources for the 2018-19 flu season. The article includes information on payment rates for 2018-19, deductible and coinsurance amounts, and provider assignments on the claim.
Effective date: N/A
Implementation date: N/A
Updated Civil Monetary Penalties and Affirmative Exclusions
On September 24, the OIG published an updated List of Civil Monetary Penalties and Affirmative Exclusions agreements, including:
- On September 14, Cindy Scott, R.B., A.P.R.N., of Tennessee, agreed to a 10-year exclusion from participation in all federal health care programs due to the submission of false claims for controlled substances that were medically unnecessary, substantially in excess of the needs of her patients, and below the professionally recognized standards of care. These prescriptions included inappropriate combinations of short and long acting opioids often combined with high amounts of benzodiazepine and/or carisoprodol. Scott also allegedly prescribed controlled substances and combinations of controlled substances with other medication without appropriately documenting a clear objective finding of a chronic pain source to justify the ongoing and increasing prescribing, attempts to identify the etiology of the pain, a thorough history or adequate inquiry into potential substance abuse history, or a written treatment plan with regard to the use of the prescriptions.
- On September 14, Anthony D. Vertino, Psy.D., of Illinois, agreed to a 20-year exclusion from participation in all federal health care programs due to the submission of claims for psychological services that were not provided as claimed.
Etheredge Chiropractic Received Unallowable Medicare Payments for Chiropractic Services
On September 26, the OIG published a Review of whether chiropractic services that Etheredge billed for complied with Medicare requirements. The OIG found that, of the 100 chiropractic services included in the sample, 33 were not allowable as 31 of these services were medically unnecessary and two of them were not documented. On the basis of the sample, the OIG estimated that Etheredge received $169,737 in unallowable Medicare payments for CYs 2014 and 2015.
The OIG recommends Etheredge refund the federal government for the $169,737 in overpayments, identify and return any similar overpayments in accordance with the 60-day rule, exercise reasonable diligence to identify and return any similar overpayments outside of the audit period, and establish adequate policies and procedures to ensure chiropractic services are medically necessary and adequately documented. Etheredge partially concurred with the recommendations but said it disagreed that 31 claims were medically unnecessary and stated it would go through the Medicare Part B appeals process.
Updated Corporate Integrity Agreement Documents
On September 27, the OIG published information on a new Corporate Integrity Agreement with the following organization:
- Norman, D.O., Robert A., Carol Norman, Dermatology Healthcare, LLC, and Robert A. Norman, D.O., P.A., of Tampa, Florida.
Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials
On September 27, the OIG published a Review regarding the rate of overturned Medicare Advantage denials upon repeal. Between 2014-2016, Medicare Advantage Organizations (MAOs) overturned 75% of their own denials, and higher levels of the appeals process overturned additional denials in favor of beneficiaries and providers during the same time. The OIG also investigated CMS oversight of these denials and found that in 2015, CMS cited 56% of audited contracts for making inappropriate denials and 45% of contracts for sending denial letters with incomplete or incorrect information. However, the OIG found that CMS continues to see the same types of violations in its audits of different MAOs every year.
The OIG recommends CMS enhance its oversight of MAO contracts and take corrective action as appropriate, address persistent problems related to inappropriate denials and insufficient denial letters in Medicare Advantage, and provide beneficiaries with clear, easily accessible information about serious violations by MAOs. CMS concurred with the recommendations.
September Edition of Patients Over Paperwork Newsletter
On September 27, CMS published the September edition of the Patients over Paperwork newsletter. The newsletter provides an overview of ways CMS is reducing burden in 2018, updates on the Requests for Information process, information learned from customer-centered workgroups, highlights of how regulatory actions have helped specific provider types, and details on the Documentation Requirement Simplification initiative.
Quarterly Influenza Virus Vaccine Code Update - January 2019
On September 27, CMS published Medicare Claims Processing Transmittal 4141, which rescinds and replaces Transmittal 4127, dated September 5, 2018, to revise business requirement 10871.6.1. The original transmittal was issued to provide the quarterly update to payment and edits in the Common Working File and Fiscal Intermediary Shared System to include and update new or existing influenza virus vaccine codes.
On September 6, CMS published a revised MLN Matters 10871 to accompany a previous revision of the transmittal.
Effective date: January 1, 2019
Implementation date: January 7, 2019
2019 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments
On September 28, CMS published Medicare Claims Processing Transmittal 4142 regarding files for automated payments of HPSA bonuses for dates of service January 1, 2019 through December 31, 2019.
CMS published MLN Matters 10968 on the same date to accompany the transmittal.
Effective date: January 1, 2019
Implementation date: January 7, 2019
Implementation of the Award for the Jurisdiction F (J-F) Part A and Part B Medicare Administrative Contractor (JF A/B MAC)
On September 28, CMS published One-Time Notification Transmittal 2143 regarding the Jurisdiction JF A/B MAC workload, which will continue to be awarded to Noridian Healthcare Solutions, LLC. The JF workload identifier numbers, the Fiscal Intermediary Shared System (FISS) roll-up identifier, and the Business Segment Identifiers (BSI) will not change.
Effective date: November 30, 2018 - Part A Effective Date; January 31, 2019 - Part B Effective Date
Implementation date: November 30, 2018 - Part A Implementation Date; January 31, 2019 - Part B Implementation Date
Confirmation of “Pickle Hospital” Status
On September 28, CMS published Medicare Claims Processing Transmittal 4138 regarding hospitals that qualify for disproportionate share hospital (DSH) payments under a special exception method. CMS wants to ensure it has a complete listing of these hospitals and is asking contractors to verify that any hospital meeting the special exception for DSH conditions is on a list provided in the transmittal. In order to qualify for the special exception, the hospital must be located in an urban area, have 100 or more beds, and be able to demonstrate that more than 30% of its total net inpatient care revenues come from state and local government sources for indigent care.
Effective date: October 29, 2018
Implementation date: October 29, 2018
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2019
On September 28, CMS published Medicare Claims Processing Transmittal 4139 to announce the changes included in the January 2019 quarterly release of the edit module for clinical diagnostic laboratory services.
CMS published MLN Matters 10941 on the same date to accompany the transmittal.
Effective date: January 1, 2019 - unless noted differently in requirements
Implementation date: January 7, 2019
Updates to Chapter 1 Payer Only Codes in the Medicare Claims Processing Manual
On September 28, CMS published Medicare Claims Processing Transmittal 4140 regarding changes to some of the Chapter 1 Payer Only Codes in the Claims Processing Manual.
Effective date: October 29, 2018
Implementation date: October 29, 2018
Guidance Regarding the Use of Statistical Sampling for Overpayment Estimation
On September 28, CMS published Medicare Program Integrity Transmittal 828 regarding updated instructions for UPICs, RACs, SMRC, and MACs in sections 8.4 through 8.4.9.2 in Chapter 8 of the Program Integrity Manual. These updated instructions contain new guidance on the use of statistical sampling in reviews and estimations of overpayments in an effort to ensure a statistically representative sample of the claim universe is drawn that yields an unbiased estimate of an overpayment.
Effective date: January 2, 2019
Implementation date: January 2, 2019
2019 Medicare Advantage and Part D Prescription Drug Program Landscape
On September 28, CMS published a Press Release and Fact Sheet regarding the 2019 Medicare Advantage and Part D Prescription Drug Program landscape. Data released with the landscape projects an all-time high in enrollment in 2019 with a projection indicating 36.7% of all Medicare beneficiaries will be enrolled through Medicare Advantage in 2019. The average monthly premium is also estimated to decrease by 6% to an average of $28 in 2019. In addition, new flexibilities available in 2019 will allow for expanded supplemental benefits, such as adult day care services, reduced cost sharing, and additional benefits for enrollees with diabetes, congestive heart failure, and other health conditions.
The files containing information on premiums and costs of Medicare health and drug plans in 2019 are available on the Prescription Drug Coverage page of the CMS website.